The Surgeon General's
Report on
NUTRITION
AND HEALTH
1988
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
DHHS (PHS) Publication No. 8840210
For sale by the Superintendent of Documents, U.S. Government Printing Of&e
Washington. DC 20402
GPO Stock Nuniber 017M)14O465-1
DEPARTMENT OF HEALTH & HUMAN SERVICES
The Surgeon General of the
Public Health Service
Waehington DC 20201
MESSAGE FROM THE SURGEON GENERAL
I am pleased to transmit to the Secretary of the Department of Health and
Human Services this first Surgeon General's Report on Nutrition and Health.
It was prepared under the auspices of the Department's Nutrition Policy
Board, and its main conclusion is that overconsumption of certain dietary
components is now a major concern for Americans. While many food
factors are involved, chief among them is the disproportionate consumption
of foods high in fats, often at the expense of foods high in complex
carbohydrates and fiber--such as vegetables, fruits, and whole grain
products--that may be more conducive to health.
I offer this Report in the context of the obligation of the Surgeon General to
inform the American public of developments in the science base that have
widespread implications for human health. Perhaps the classic example of
such reports is the one issued in 1964 during the tenure of one of my
predecessors, Dr. Luther Terry, which summarized the epidemiologic
evidence available at the time on the relationship of tobacco to health. This
report called attention to the inescapable conclusion that cigarettes were a
major source of illness and death for those who smoked--at that time a
majority of adult men.
This Surgeon General's Report on Nutrition and Health follows the tradition
of the original report on smoking and health. It addresses an area of some
controversy and substantial misunderstanding. And the relative magnitude
of the associated health concerns is comparable, with dietary factors playing
a prominent role in five of the ten leading causes of death for Americans. In
addition, the depth of the science base underlying its findings is even more
impressive than that for tobacco and health in 1964, with animal and clinical
evidence adding to the epidemiologic studies.
On the other hand there are some fundamental differences. Most obvious is
the fact that food is necessary for good health. Foods contain nutrients
essential for normal metabolic function, and when problems arise, they
result from imbalance in nutrient intake or from harmful interaction with
other factors. Moreover, we know today much more about individual
variation in response to nutrients than we know about possible variations in
response to tobacco. Some people are clearly more susceptible than others
to problems from diets that are, for example, higher in fat or salt.
Also, unlike the experience for tobacco in 1964, people are already making
dietary changes, as witnessed by the shift to products lower in saturated fats.
Nonetheless, the important effects of the dietary factors underlying
problems like coronary heart disease, high blood pressure, stroke, some
types of cancer, diabetes, obesity--problems that represent the leading health
threats for Americans--indicate the potential for substantial gains to be
accrued by the recommendations contained in this Report
It is important to emphasize that the focus of this Report is primarily on the
relationship of diet to the occurrence of chronic diseases. The Report is not
intended to address the problems of hunger or undernutrition that may
occur in the United States among certain subgroups uf the population. All
Americans should have access to an appropriate diet, but they do not. And
even though the size and numbers of problems related to inadequate access to
food are proportionately much smaller than those related to dietary excesses
and imbalances, the problems of access to food are of considerable concern
to me, personally, wherever they may occur.
The apparently sizable numbers of people resorting to the use of soup
kitchens and related food facilities, as well as the possible role of poor diet as
a contributor to the higher infant mortality rates associated with inadequate
income, suggest the need for better monitoring of the nature and extent of
the problem and for sustained efforts to correct the underlying causes of
diminished health due to inadequate or inappropriate diets.
This report was prepared primarily for nutritional policy makers, although
the eventual beneficiaries of better nutritional policy will be the American
people. I am convinced that with a concerted effort on the part of policy
makers throughout the Nation, and eventually by the public, our daily diets
can bring a substantial measure of better health to all Americans. I
commend to them the recommendations of this Report.
C. Everett Koop, M.D., Sc.D.
Surgeon General
U.S. Public Health Service
This first Surgeon General's Report on Nutrition and Health marks a key
event in the history of public health in the United States. While the Report
has been developed for use by policymakers, it offers lessons that can be
directly applied to the public. It responds to the increasing interest of
scientists, health professionals, and the American people in the role of diet
in health promotion. Within recent years, concerns about nutrition and
health have expanded beyond the need to prevent deficiencies to encom-
pass the effects of typical American dietary patterns on the incidence of
chronic diseases that are leading causes of death and disability in this
country. Although scientific research has provided substantial insight into
the ways specific dietary factors influence specific diseases, there are still
many uncertainties about diet-disease relationships. The Department of
Health and Human Services, through the Public Health Service and the
Surgeon General, welcomes the responsibility to evaluate the current state
of knowledge and to advise the public accordingly.
This Report reviews the scientific evidence that relates dietary excesses
and imbalances to chronic diseases. On the basis of the evidence, it
recommends dietary changes that can improve the health prospects of
many Americans. Of highest priority among these changes is to reduce
intake of foods high in fats and to increase intake of foods high in complex
carbohydrates and fiber.
The evidence presented here indicates the convergence of similar dietary
recommendations that apply to prevention of multiple chronic diseases.
The recommendation to reduce dietary fat, for example, aims to reduce the
risk for coronary heart disease, diabetes, obesity, and some types of
cancer. This advice is not new, But it is now substantiated by a large body of
evidence derived from many different kinds of research-a research base
that is now even more comprehensive than was the case for the pioneering
1964 Surgeon General's Report on Smoking and Health.
The weight of this evidence and the magnitude of the problems at hand
indicate that it is now time to take action. In the cause of good health for all
our citizens, I urge support for this Report's recommendations by every
sector of American society.
Otis R. Bowen, M.D.
Secretary
V
Preface
The Public Health Service of the Department of Health and Human Ser-
vices has long maintained an interest in the relationship between food and
health. In the 1970's, this interest began to focus on the ways in which
dietary excesses and imbalances increase the risk for chronic diseases.
With the publication in 1979 of Healthy People: The Surgeon General's
Report on Health Promotion and Disease Prevention, attention turned
toward environmental and behavioral changes that Americans might make
to reduce their risks for morbidity and mortality. Nutrition was one such
priority area. The 1980 report Promoting HealthlPreventing Disease: Ob-
jectives for the Nation included 17 specific, quantifiable objectives in
nutrition designed to reduce risks and to prevent illness and death. Also in
1980, the Department published, jointly with the U.S. Department of
Agriculture, the first edition of Dietary Guidelines for Americans. This
report, revised in 1985, includes seven recommendations that, taken to-
gether, address the relationship between diet and chronic diseases.
Diseases such as coronary heart disease, stroke, cancer, and diabetes
remain leading causes of death and disability in the United States. Substan-
tial scientific research over the past few decades indicates that diet can play
an important role in prevention of such conditions. The Public Health
Service has now reviewed this research and has produced a comprehensive
analysis of the relationship between dietary factors and chronic disease
risk. This Surgeon GeneralS Report on Nutrition and Health summarizes
research on the role of diet in health promotion and disease prevention. Its
findings indicate the great importance of diet to health. They demonstrate
that changes in present dietary practices of Americans could produce
substantial gains in the health of the population. The Public Health Service
is committed to improving the health of Americans through its programs in
education, services, and research.
One mechanism for improving the health of Americans is through the 1990
Health Objectives for the Nation. The role of nutrition in health will
continue to be a focus of national health priorities as we develop new
objectives for the year 2000. Federal, State, and local governments, the
American public, the food industry, and scientists and health professionals
can work together to encourage Americans to make healthy food choices
and to achieve national health goals.
vii
1 am pleased to commend to the American people this review of the
scientific evidence that links diet to chronic disease, and I urge that the
findings of this important Report be given your careful consideration.
Robert E. Windom, M.D.
Assistant Secretary for Health
. . .
vu1
Contents
Foreword .................................................... v
Preface ..................................................... vii
Nutrition Policy Board ....................................... xiv
Acknowledgments ............................................ xv
Summary and Recommendations ................................ 1
Chapter 1: Introduction and Background ........................ 2 1
Chapter 2: Coronary Heart Disease ............................. 83
Chapter 3: High Blood Pressure ............................... 139
Chapter4:Cancer ........................................... 177
Chapter 5: Diabetes .......................................... 249
Chapter6:Obesity.. ......................................... 275
Chapter 7: Skeletal Diseases .................................. 3 11
Chapter 8: Dental Diseases ................................... 345
Chapter9:KidneyDiseases ................................... 381
Chapter 10: Gastrointestinal Diseases .......................... 403
Chapter 11: Infections and Immunity .......................... 427
Chapter 12: Anemia .......................................... 465
Chapter 13: Neurologic Disorders ............................. 491
Chapter 14: Behavior ........................................ 509
,
Chapter 15: Maternal and Child Nutrition ...................... 539
Chapter16:Aging ........................................... 595
Chapter 17: Alcohol .......................................... 629
Chapter 18: Drug-Nutrient Interactions ......................... 67 1
Chapter 19: Dietary Fads and Frauds .......................... 695
Index ...................................................... 713
ix
Tables
1.
2.
l-l.
l-2.
l-3.
l-4.
l-5.
l-6.
l-7.
1-8.
l-9.
2-l.
2-2.
2-3.
2-4.
Recommendations..................................... 3
Estimated Total Deaths and Percent of Total Deaths for the 10
Leading Causes of Death: United States, 1987 . . . . . . . . . . . . . 4
Estimated Total Deaths and Percent of Total Deaths for the 10 +
Leading Causes of Death: United States, 1987 . . . . . . . . . . . . . 22
Selected Events in the History of Nutritional Science
to1950............................................... 25
Selected Federal Domestic Nutrition Policy Initiatives,
1862-1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
National Nutrition Surveillance Activities . . . . . . . . . . . . . . . . 38
Federal Dietary Recommendations for the General Public,
1917-1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Food and Nutrition Board, National Academy of Sciences-
National Research Council Recommended Daily Dietary
Allowances, Revised 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Estimated Safe and Adequate Daily Intakes of Selected
VitaminsandMinerals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Annual Per Capita Availability of Selected Commodities in
the U.S. Food Supply, 1%5-1985 . . . . . . . . . . . . . . . . . . . . . . . . 65
Mean Daily Intake of Food Energy, Nutrients, and Food
Components for Men, Women, and Young Children From the
Continuing Survey of Food Intakes by Individuals (CSFII),
1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Death Rate for Coronary Heart Disease by Age, Race, and
Sex, United States, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Prevalence of Coronary Heart Disease by Age, Race, and
Sex, United States, 1985 . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . 86
National Cholesterol Education Program Adult Treatment
Panel Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Estimates of Serum Cholesterol Change From Given Changes
in Dietary Lipids Based on Isocaloric Controlled
Experiments in Humans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
X
3-1.
3-2.
3-3.
3-4.
3-5.
3-6.
3-7.
4-l.
4-2.
4-3.
4-4.
4-5.
4-6.
4-7.
4-8.
,
4-9.
4-10.
Classification of Blood Pressure in Adults 18 Years or
Older ................................................ 143
Estimated Prevalence of Cardiovascular Disease in the United
States ................................................ 143
Control Mechanisms for Arterial Pressure ................ 145
Major Nutrients and Possible Mechanisms for Influencing
BloodPressure.. ...................................... 147
Changes in Weight and Blood Pressure (Baseline to Followup)
in Treatment (Rx) and Control Groups of Five Randomized
ControlledTrials ...................................... 149
Studies of Cross-Sectional Association of Blood Pressure
With Alcohol Consumption ............................. 154
Prospective Observational Studies of the Association of Blood
Pressure With Alcohol Consumption ..................... 155
Proportions of Cancer Deaths Attributed to Various
Factors ............................................... 180
International Changes Since 1950 in Death Certification
Rates for Cancers of Stomach and Lung .................. 181
Cancer Incidence Rates in the Philippines and Among
Filipinos and Caucasians in Hawaii ...................... 182
Reported Relationship Between Selected Dietary
ComponentsandCancer ............................... 191
National Cancer Institute Dietary Guidelines .............. 192
Comparison of Dietary Guidelines for the
American Public ...................................... 193
Summary of Epidemiologic Studies Examining Dietary Fat
andBreastCancer ..................................... 196
Retrospective Human Studies Relating Body Weight and
Cancer ............................................... 200
Summary of Epidemiologic Studies Examining Dietary Fiber
and Colon Cancer ..................................... 205
Dietary Vitamin A and Lung Cancer Risk: A Summary of
PreviousStudies ...................................... 211
xi
4-l 1. NCI-Sponsored Prevention Clinical Trials Related to
VitaminA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
4-12.
5-l.
5-2.
5-3.
6-l.
6-2.
6-3.
7-l.
8-l.
Summary of Epidemiologic Studies on Selenium and
CancerRisk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
History of Dietary Composition (Relative Proportion of
Carbohydrate and Fat Calories) Used in Management of ,
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Clinical Complications of Diabetes . . . . . . . . . . . . . . . . . . . . . . . 255
American Diabetes Association Dietary Recommendations
for Persons With Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Comparison of Metropolitan Desirable Weights With Average
Weights From U.S. Cohort Studies . . . . . . . . . . . . . . . . . . . . . . 282
Body Mass Index (kg/m*) Used to Define Desirable Weight
and Overweight According to Three Different "Ideal"
Reference Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Mortality Ratios for All Ages Combined in Relation to the
Death Rate of Those 90 to 109 Percent of Average Weight . . . 290
Scientific Validity of Risk Factors . . . . . . . . . . . . . . . . . . . . , . . . 314
Supplemental Fluoride Dosage Scheduled (in mg F/day)
According to Fluoride Concentrations of Drinking Water . . . 359
10-I. Summary of Digestive Processes . . . . . . . . . . . . . . . . . . . . . . . . 407
10-2. Gastrointestinal Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
1 l-l. Causes of Food-Associated Illness . . . . . . . . . . . . . . . . . . . . . . . 448
12-I. Estimates for Percent Prevalence of Impaired Iron Status:
Average of Estimates Using Three Methods: NHANES II,
1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468
12-2. Total Body Iron and Storage Iron . . . . . . . . . . . . . . . . . . . . . . . . 471
14-1. Behavioral and Psychologic Hypotheses to Explain
Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
14-2. Diagnostic Criteria for Anorexia Nervosa and Bulimia . . . . . . 520
15-1. Selected National Objectives to be Achieved by the Year 1990
Related to Maternal and Child Nutrition . . . . . . . . . . . . . . . . . . 545
xii
15-2. Content of Selected Nutrients in Human Milk, Commercial
Formulas, and Other Milks Used for Feeding Normal Full-
TermInfants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565
Figures
l-l. Dependence of Biologic Function or Tissue Concentration on
Intake of a Nutrient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2-l. Diagram of an Atherosclerotic Plaque . . . . . . , . . . . . . . . . . . . . 88
4-l. Range of Incidence Rates (International Comparisons) . . . . . 180
4-2. Carcinogenesis........................................ 183
4-3. Dietary Fat Intake in Relation to Breast Cancer-Related Death
Rate................................................. 187
6-l. A Nomogram for Determining Body Mass Index (BMI) . . . . 284
8-l. The Distribution of Mean Decayed and Filled Coronal
Surfaces (DFS) by Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
8-2. The Distribution of Mean Decayed and Filled Root Surfaces
(DFS) by Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
8-3. Percent of Persons by Severe Loss of Periodontal
Attachment (Pocket Depths Measuring 4 mm or More)
andAgeGroups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
8-4. Comparison of the Percent of Edentulous Persons in the
1985-86 NIDR Survey to That Reported From the NCHS
Surveyof1960-62 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
8-5. Schematic Cross-Section of a Typical Mandibular Molar
Tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
9-l. The Comparative Structures of Amino Acids, Ketoacids, and
Hydroxyacids......................................... 391
. . .
Xl11
Nutrition Policy Board
U.S. Department of Health and Human Services
J. Michael McGinnis, M.D. (Chairman), Deputy Assistant Secretary for
Health (Disease Prevention and Health Promotion), Public Health Service -
Faye G. Abdellah, R.N., Ed.D., Sc.D., Deputy Surgeon General, Public
Health Service
W. Douglas Badger, M.Div., Deputy Assistant Secretary, Office of Human
Development Services
Mary M. Ever& M.B.A., Director, Office of Community Services, Family
Support Administration
Manning Feinleib, M.D., M.P.H., Dr.P.H., Director, National Center for
Health Statistics, Centers for Disease Control, Public Health Service
Allan L. Forbes, M.D., Director, Office of Nutrition and Food Sciences,
Center for Food Safety and Applied Nutrition, Food and Drug Administra-
tion, Public Health Service
William T. Friedewald, M.D., Associate Director for Disease Prevention,
National Institutes of Health, Public Health Service
Bernard I. Grosser, M.D., Director, Office of Science, Alcohol, Drug
Abuse, and Mental Health Administration, Public Health Service
John Porvaznik, M.D., F.A.C.S., Associate Director, Office of Health
Programs, Indian Health Service, Public Health Service
William A. Robinson, M.D., M.P.H., Chief Medical OBicer, Health Re-
sources and Services Administration, Public Health Service
xiv
Acknowledgments
The Surgeon General's Report on Nutrition and Health was prepared
under the general editorship of the Department of Health and Human
Services' Nutrition Policy Board, whose members are listed on the pre-
vious page. Managing Editor was Marion Nestle, Ph.D., M.P.H., Office of
Disease Prevention and Health Promotion. Special editorial assistance was
contributed by John Bailar III, M.D., Ph.D., Science Advisor, Office of
Disease Prevention and Health Promotion, and by Darla E. Danford,
M.P.H., D.Sc., R.D., National Institutes of Health. Project Officer during
early stages of preparation of the Report was Ann Sorenson, Ph.D., now
with the National Institutes of Health.
In addition to the guidance of the Nutrition Policy Board's Senior Editorial
Advisors and Staff Working Group, important editorial contributions were
made by Karen Donato, M.S., R.D., Nancy D. Ernst, M.S., R.D., Marilyn
E. Farrand,M.S.,R.D.,andVanS. Hubbard,M.D.,Ph.D.,oftheNation-
al Institutes of Health's Nutrition Education Subcommittee; and by Walter
H. Glinsmann, M.D., Marilyn G. Stephenson, M.S., R.D., John E. Van-
derveen, Ph.D., and Elizabeth Yetley, Ph.D., R.D., of the Food and Drug
Administration's Center for Food Safety and Applied Nutrition.
Senior Editorial Advisors to the Nutrition Policy Board were:
C. Wayne Callaway, M.D., Director, Center for Clinical Nutrition, George
Washington University Medical Center, Washington, D.C.
`Johanna T. Dwyer, D.Sc., Director, Frances Stem Nutrition Center, New
England Medical Center Hospitals, and Professor of Medicine, Tufts Uni-
versity Medical School, Boston, Massachusetts
Samuel Fomon, M.D., Professor of Pediatrics, University of Iowa, Iowa
City, Iowa
Richard L. Hall, Ph.D., Vice President, Science and Technology, McCor-
mick & Co., Inc., Hunt Valley, Maryland
Robert I. Levy, M.D., President, Sandoz Research Institute, East Hano-
ver, New Jersey
Walter Mertz, M.D., Director, Beltsville Human Nutrition Research Cen-
ter, U.S. Department of Agriculture, Beltsville, Maryland
xv
Malden C. Nesheim, Ph.D., Vice President for Planning and Budget,
Cornell University, Ithaca, New York
Sushma Palmer, D.Sc., Executive Director, Food and Nutrition Board,
National Academy of Sciences, Washington, D.C.
Irwin H. Rosenberg, M.D., Director, USDA Human Nutrition Research
Center on Aging, Tufts University, Boston, Massachusetts
Theodore Van Itallie, M.D., Professor of Medicine, Columbia University
College of Physicians and Surgeons, New York, New York
Nutrition Policy Board Staff Working Group members were:
Elizabeth Brannon, M.S., R.D., Clinical Nutrition Specialist, Bureau of
Maternal and Child Health and Resources Development, Health Resourc-
es and Services Administration, Rockville, Maryland
Darla E. Danford, M.P.H., D.Sc., R.D., Nutritionist, Nutrition Coordinat-
ing Committee, National Institutes of Health, Bethesda, Maryland
Willie M. Etheridge, M.S., Policy Analyst, Policy Planning and Legislation
Division, Office of Human Development Services, Washington, D.C.
James J. Heam, L.L.B., Chief, Community Food and Nutrition Program,
Office of Community Services, Family Support Administration, Washing-
ton, D.C.
M. Yvonne Jackson, Ph.D., R.D., Chief, Nutrition and Dietetics Section,
Indian Health Service, Rockville, Maryland
Linda D. Meyers, Ph.D., Nutrition Advisor, Office of Disease Prevention
and Health Promotion, Washington, D.C.
Marion Nestle, Ph.D., M.P.H., Director, Nutrition Policy Staff, Office of
Disease Prevention and Health Promotion, Washington, D.C.
Lana Skirboll, Ph.D., Special Assistant to the Director, Offtce of Science,
Alcohol, Drug Abuse, and Mental Health Administration, Rockville,
Maryland
Frederick Trowbridge, M.D., M.S., Director, Nutrition Division, Center
for Health Promotion and Education, Centers for Disease Control, Atlan-
ta, Georgia
xvi
Catherine E. Woteki, Ph.D., R.D., Deputy Director, Division of Health
Examination Statistics, National Center for Health Statistics, Centers for
Disease Control, Hyattsville, Maryland
Individuals who contributed to the writing of draft chapters or
portions of the Report were:
Margaret J. Albrink, M.D., M.P.H., Professor of Medicine, West Virginia
University Medical Center, Morgantown, West Virginia (Obesity)
William R. Beisel, M.D., Adjunct Professor, Department of Immunology
and Infectious Diseases, School of Hygiene and Public Health, The Johns
Hopkins University, Baltimore, Maryland (Infections and Immunity)
C. Wayne Callaway, M.D., Director, Center for Clinical Nutrition, George
Washington University Medical Center, Washington, D.C. (Alcohol)
Joseph E. Ciardi, Ph.D., Research Biochemist, Caries and Restoration
Materials Research Branch, Extramural Program, National Institute of
Dental Research, National Institutes of Health, Bethesda, Maryland (Den-
tal Diseases)
Phyllis A. Crapo, R.D., Department of Medicine, University of California
at San Diego, LaJolla, California (Diabetes)
Jeffrey A. Cutler, M.D., Chief, Prevention and Demonstration Research
Branch, National Heart, Lung, and Blood Institute, National Institutes of
Health, Bethesda, Maryland (High Blood Pressure)
Peter R. Dallman, M.D., Professor, Department of Pediatrics, University
of California, San Francisco, California (Anemia)
Barbara H. Dennis, R.D., Ph.D., Division of Heart and Vascular Diseases,
National Heart, Lung, and Blood Institute, National Institutes of Health,
Bethesda, Maryland (Coronary Heart Disease)
John Duguid, M.D., Ph.D., Neurologist, Massachusetts Institute of Tech-
nology, Cambridge, Massachusetts (Neurologic Disorders)
Robert Edelman, M.D., Chief, Clinical and Epidemiological Studies
Branch, Deputy Director, Microbiology and Infectious Diseases Program,
National Institute of Allergy and Infectious Diseases, National Institutes
of Health, Bethesda, Maryland (Infections and Immunity)
xvii
Nancy D. Ernst, MS., R.D., Nutrition Coordinator, National Heart,
Lung, and Blood Institute, National Institutes of Health, Bethesda, Mary-
land (High Blood Pressure)
Lloyd J. Filer, Jr., M.D., Ph.D., Department of Pediatrics, University of
Iowa School of Medicine, Iowa City, Iowa (Maternal and Child Nutrition)
Mattie R.S. Fox, Ph.D., Chief, Nutrient Interaction Section, Experimental
Nutrition Branch, Division of Nutrition, Food and Drug Administration,
Washington, D.C. (Introduction and Background)
Philip J. Garry, Ph.D., Professor, Department of Pathology, University of
New Mexico School of Medicine, Albuquerque, New Mexico (Aging)
James Goodwin, M.D., Professor and Vice Chairman, Department of
Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (Aging)
Sheila Gottschalk, M.D., Associate Professor of Pediatrics, Louisiana
State University School of Medicine, New Orleans, Louisiana (Maternal
and Child Nutrition)
,
Gregory E. Gray, M.D., Ph.D., Assistant Professor, Department of Psy-
chiatry and the Behavioral Sciences, Los Angeles County-University of
Southern California Medical Center, Los Angeles, California (Behavior)
Peter Greenwald, M.D., lX.P.H., Director, Division of Cancer Prevention
and Control, National Cancer Institute, National Institutes of Health,
Bethesda, Maryland (Cancer)
John H. Growdon, M.D., Massachusetts Institute of Technology, Massa-
chusetts General Hospital, and Harvard Medical School, Cambridge, Mas-
sachusetts (Neurologic Disorders)
Margaret A. Hamburg, M.D., Special Assisiant to the Director, National
Institute of Allergy and Infectious Diseases-, National Institutes of Health,
Bethesda, Maryland (Infections and Immunity)
James P. Hat-wood, Ph.D., Executive Secretary, Scientific Review Office,
National Institute on Aging,-National Institutes of Health, Bethesda,
Maryland (Introduction and Background)
Michael Horan, M.D., Chief, Hypertension and Kidney Diseases Branch,
National Heart, Lung, and Blood Institute, National Institutes of Health,
Bethesda, Maryland (High Blood Pressure)
Richard D. Hurt, M.D., Mayo Clinic, Rochester, Minnesota (Alcohol)
. .
XVlll
Howard Jacobson, M.D., Institute of Nutrition, University of North Car-
olina, Chapel Hill, North Carolina (Maternal and Child Nutrition)
Mamie Y. Jenkins, Ph.D., Research Chemist, Bioavailability Section,
Experimental Nutrition Branch, Division of Nutrition, Food and Drug
Administration, Washington, D.C. (Introduction and Background)
Alexander Jordan, Ph.D., Supervisory Pharmacologist, Food and Drug
Administration, Rockville, Maryland (Drug-Nutrient Interactions)
George M. Kazzi, M.D., Chief, Department of Obstetrics and Gynecolo-
gy, Harper-Grace Hospitals, and Assistant Professor, Maternal-Fetal
Medicine, Wayne State University School of Medicine, Detroit, Michigan
(Maternal and Child Nutrition)
Joel D. Kopple, M.D., Professor of Medicine and Public Health, Univer-
sity of California at Los Angeles, Chief, Division of Nephrology and
Hypertension, Harbor-UCLA Medical Center, Torrance, California (Kid-
ney Diseases)
Markus J.P. Kruesi, M.D., Staff Psychiatrist, National Institute of Mental
Health, Alcohol, Drug Abuse, and Mental Health Administration, Rock-
ville, Maryland (Behavior)
Elaine Lanza, Ph.D., Diet and Cancer Branch, Division of Cancer Preven-
tion and Control, National Cancer Institute, National Institutes of Health,
Bethesda, Maryland (Cancer)
Harris R. Lieberman, Ph.D., Department of Brain and Cognitive Sciences,
Massachusetts Institute of Technology, Cambridge, Massachusetts (Neu-
, rologic Disorders; Behavior)
Gardner C. McMillan, M.D., Division of Heart and Vascular Diseases,
National Heart, Lung, and Blood Institute, National Institutes of Health,
Bethesda, Maryland (Coronary Heart Disease)
Albert I. Mendeloff, M.D., M.P.H., Department of Medicine, The Johns
Hopkins University School of Medicine, Baltimore, Maryland (Gastroin-
testinal Diseases)
Linda D. Meyers, Ph.D., Nutrition Advisor, Office of Disease Prevention
and Health Promotion, Washington, D.C. (Introduction and Background)
Sanford A. Miller, Ph.D., Director, Center for Food Safety and Applied
Nutrition, Food and Drug Administration, Washington, D.C. (Introduction
and Background)
xix
Geraldine V. Mitchell, Ph.D., Chief, Bioavailability Section. Experimental
Nutrition Branch, Division of Nutrition. Food and Drug Administration,
Washington, D.C. (Introduction and Background)
Eliot N. Mostow, M.D., M.P.H., Medical Staff Fellow, Division of Cancer
Prevention and Control, National Cancer Institute, National Institutes of
Health, Bethesda, Maryland (Cancer)
Jerrold M. Olefsky, M.D., Department of Medicine, University of Califor-
nia at San Diego, and San Diego Veterans Administration Medical Center,
San Diego, California (Diabetes)
Youngmee K. Park, Ph.D., Nutritionist, Clinical Nutrition Branch, Divi-
sion of Nutrition, Food and Drug Administration, Washington, D.C. (Intro-
duction and Background)
Jean A.T. Pennington, Ph.D., Assistant to the Director, Division of Nutri-
tion, Food and Drug Administration, Washington, D.C. (Introduction and
Background)
L. Ross Pierce, M.D., Group Leader, Food and Drug Administration,
Rockville, Maryland (Drug-Nutrient Interactions)
Peggy L. Pipes, M.P.N., R.D., Child Development Mental Retardation
Center, University of Washington, Seattle, Washington (Maternal and
Child Nutrition)
Ernest0 Pollitt, Ph.D., Department of Applied Behavioral Sciences, Uni-
versity of California, Davis, California (Maternal and Child Nutrition)
Leon Prosky, Ph.D., Deputy Chief, Experimental Nutrition Branch, Divi-
sion of Nutrition, Food and Drug Administration, Washington, D.C. (Intro-
duction and Background)
Jeanne I. Rader, Ph.D., Chief, Nutrient Toxicity Section, Experimental
Nutrition Branch, Division of Nutrition, Food and Drug Administration,
Washington, D.C. (Introduction and Background)
Lawrence G. Raisz, M.D., Professor of Medicine and Chief, Division of
Endocrinology and Metabolism, University of Connecticut School of Med-
icine, Farmington, Connecticut (Skeletal Diseases)
Judith L. Rapoport, M.D., Chief, Child Psychiatry Branch, National Insti-
tute of Mental Health, Alcohol, Drug Abuse, and Mental Health Adminis-
tration, Rockville, Maryland (Behavior)
xx
Merrill S. Read, Ph.D., Professor and Chairman, Human Nutrition and
Food Systems, College of Human Ecology, University of Maryland, Col-
lege Park, Maryland (Maternal and Child Nutrition)
Basil M. Rifkind, M.D., F.R.C.P., Division of Heart and Vascular Dis-
eases, National Heart, Lung, and Blood Institute, National Institutes of
Health, Bethesda, Maryland (Coronary Heart Disease)
Norman E. Rosenthal, M.D., Chief, Unit on Outpatient Studies, Clinical
Psychology Branch, National Institute of Mental Health, Alcohol, Drug
Abuse, and Mental Health Administration, Rockville, Maryland (Behav-
ior)
Neil L. Sass, Ph.D., Senior Scientist, ORice of Management, Center for
Food Safety and Applied Nutrition, Food and Drug Administration, Wash-
ington, D.C. (Introduction and Background)
Claudia Schuth, M.D., Associate Professor of Pediatrics, Louisiana State
University School of Medicine, New Orleans, Louisiana (Maternal and
Child Nutrition)
James H. Shaw, Ph.D., Professor of Nutrition Emeritus, Harvard School of
Dental Medicine, Boston, Massachusetts (Dental Diseases)
Alan J. Sheppard, Ph.D., Chief, Experimental Methods Research Section,
Nutrient Surveillance Branch, Division of Nutrition, Food and Drug Ad-
ministration, Washington, D.C. (Introduction and Background)
Solomon Sobel, M.D., Food and Drug Administration, Rockville, Mary-
land (Drug-Nutrient Interactions)
Robert J. Sokol, M.D., Professor and Chairman and Chief, Department of
Obstetrics and Gynecology, Wayne State University, Hutzel Hospital,
Detroit, Michigan (Maternal and Child Nutrition)
Marilyn G. Stephenson, M.S., R.D., Assistant to the Director, OfIice of
Nutrition and Food Sciences, Center for Food Safety and Applied Nutri-
tion, Food and Drug Administration, Washington, DC. (Dietary Fads and
Frauds)
Albert Stunkard, M.D., Professor of Psychiatry, University of Pennsylva-
nia School of Medicine, Philadelphia, Pennsylvania (Behavior)
Robert M. Suskind, M.D., Department of Pediatrics, Louisiana State
University School of Medicine, New Orleans, Louisiana (Maternal and
Child Nutrition)
xxi
Shyy Hwa Tao, Ph.D., Research Chemist, Nutrient Interaction Section,
Experimental Nutrition Branch, Division of Nutrition, Food and Drug
Administration, Washington, D.C. (Imroduction and Background)
Thomas Thorn, Statistician, Epidemiology and Biometry Research Pro-
gram, Division of Epidemiology and Clinical Applications, National Heart,
Lung, and Blood Institute, National Institutes of Health, Bethesda, Mary-
land (Coronary Heart Disease)
Gloria Troendle, M.D., Deputy Director, Food and Drug Administration,
Rockville, Maryland (Drug-Nutrient Interactions)
Momtaz Wassef, Ph.D., Division of Heart and Vascular Diseases, National
Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda,
Maryland (Coronary Heart Disease)
Cora E. Weeks, J.D., Ph.D., Consumer Safety Officer, Division of Reg-
ulatory Guidance, Center for Food Safety and Applied Nutrition, Food and
Drug Administration, Washington, D.C. (Introduction and Background)
Robert W. Wissler, M.D., Ph.D., Donald N. Pritzker Distinguished Service
Professor of Pathology Emeritus, University of Chicago, Chicago, Illinois
(Coronary Heart Disease)
Philip A. Wolf, M.D., Professor of Neurology and Associate Research
Professor of Medicine, Preventive Medicine and Epidemiology, Boston
University School of Medicine, Boston, Massachusetts (Neurologic Disor-
ders)
Bonnie S. Worthington-Roberts, Ph.D., Professor, Nutritional Sciences,
University of Washington, Child Development Center, Seattle, Washington
(Maternal and Child Nutrition)
Catherine E. Woteki, Ph.D., R.D., Deputy Director, Division of Health
Examination Statistics, National Center for Health Statistics, Centers for
Disease Control, Hyattsville, Maryland (Introduction and Background)
Richard J. Wurtman. M.D., Professor, Department of Brain and Cognitive
Sciences, Director, Clinical Research Center, Massachusetts Institute of
Technology, Cambridge, Massachusetts (Neurologic Disorders; Behavior)
Elizabeth Yetley, Ph.D., R.D., Chief, Clinical Nutrition, Division of Nutri-
tion, Office of Nutrition and Food Sciences, Center for Food Safety and
Applied Nutrition, Food and Drug Administration, Washington, D.C. (In-
troduction and Background)
xxii
During preparation of the Report, chapters were subjected to six stages of
critical review, three by experts within the Public Health Service (internal
reviews) and three by scientists and professionals recommended as experts
by national scientific and nutrition professional organizations in the private
sector (external reviews). In addition, the senior editorial advisors and staff
to the Nutrition Policy Board listed above provided expert technical eval-
uation throughout the review process.
Individuals who reviewed chapters or potions of the Report were:
Phyllis B. Acosta, Dr.P.H., R.D., Director of Metabolic Diseases, Ross
Laboratories, Columbus, Ohio
Lawrence Agodoa, M.D., Coordinator, National Institute of Diabetes and
Digestive and Kidney Diseases, National Institutes of Health, Bethesda,
Maryland
Duane F. Alexander, M.D., Director, National Institute of Child Health
and Human Development, National Institutes of Health, Bethesda, Mary-
land
Aaron M. Altschul, Ph.D., Diet Management and Eating Disorders Pro-
gram, Georgetown University, Washington, D.C.
Ronald A. Arky, M.D., Professor, Department of Medicine, Harvard
Medical School at Mt. Auburn Hospital, Cambridge, Massachusetts
Louis Avioli, M.D., Professor of Medicine and Oral Biology, Washington
University School of Medicine and Dental School, St. Louis, Missouri
David Badman, Ph.D., Hematology Program Director, National Institute
of Diabetes and Digestive and Kidney Diseases, National Institutes of
Health, Bethesda, Maryland
John Bailar III, M.D., Ph.D., Science Advisor, Office of Disease Preven-
tion and Health Promotion, Washington, D.C.
David H. Baker, Ph.D., Professor of Nutrition and Metabolism, Univer-
sity of Illinois, Urbana, Illinois
Susan Blumenthal, M.D., Medical Oflicer and Chief, Behavioral Medicine
Program, National Institute of Mental Health, Alcohol, Drug Abuse, and
Mental Health Administration, RockvilIe, Maryland
Ronette Briefel, Dr.P.H., R.D., Nutritional Epidemiologist, Survey Plan-
ning and Development Branch, National Center for Health Statistics,
Centers for Disease Control, Hyattsville, Maryland
. . .
xx111
Benjamin Burton, Ph.D., Associate Director for Disease Prevention and
Technology Transfer, National Institute of Diabetes and Digestive and
Kidney Diseases, National Institutes of Health, Bethesda, Maryland
Ritva Butrum, Ph.D., Diet and Cancer Branch, Division of Cancer Preven-
tion and Control, National Cancer Institute, National Institutes of Health,
Bethesda, Maryland
Charles E. Butterworth, Jr., M.D., Director, Clinical Nutrition Research
Unit, University of Alabama, Birmingham, Alabama
George F. Cahill, Jr., M.D., Howard Hughes Medical Institute, Boston,
Massachusetts
Doris H. Calloway, Ph.D., Provost Professor Schools and College, Uni-
versity of California, Berkeley, California
Richard Calve& M.D., Medical Research Nutritionist, Experimental Nu-
trition Branch, O&e of Nutrition and Food Sciences, Center for Food
Safety and Applied Nutrition, Food and Drug Administration, Washing-
ton, D.C.
Mona Calvo, Ph.D., R.D., Nutritionist, Clinical Nutrition, Division of
Nutrition, Office of Nutrition and Food Sciences, Center for Food Safety
and Applied Nutrition, Food and Drug Administration, Washington, D.C.
James P. Carlos, D.D.S., Chief, Epidemiology Branch, Epidemiology and
Oral Disease Prevention Program, National Institute of Dental Research,
National Institutes of Health, Bethesda, Maryland
Kenneth K. Carroll, Ph.D., Professor, Department of Biochemistry, Uni-
versity of Western Ontario, London, Ontario, Canada
Ranjit K. Chandra, M.D., F.R.C.P., Janeway Child Health Center, Immu-
nology Department, St. John's, Newfoundland, Canada
Lois Chatham, Ph.D., Director, Division of Basic Research, National
Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and
Mental Health Administration, Rockville; Maryland
Aram V. Chobanian, M.D., Director and Professor, Cardiovascular Insti-
tute, Boston University School of Medicine, Boston, Massachusetts
Joginder G. Chopra, M.D., Special Assistant, Medical Affairs, Office of
Nutrition and Food Sciences, Center.for Food Safety and Applied Nutri-
tion, Food and Drug Administration, Washington, D.C.
Gregory Christenson, Ph.D., Special Population Studies Branch, Division
of Cancer Prevention and Control, National Cancer Institute, National
Institutes of Health, Bethesda, Maryland
Carolyn Clifford, Ph.D., Diet and Cancer Branch, Division of Cancer
Prevention and Control, National Cancer Institute, National Institutes of
Health, Bethesda, Maryland
James D. Cook, M.D., Division of Hematology, University of Kansas
Medical Center, Kansas City, Kansas
Stephen B. Corbin, D.D.S., M.P.H., Senior Prevention Policy Advisor,
Prevention Policy Staff, OfIice of Disease Prevention and Health Promo-
tion, Washington, D.C.
Ann Coulston, M.S., R.D., Clinical Research Center, Stanford University
Hospital, Stanford, California
Frances Cronin, Ph.D., R.D., Chief, Diet Appraisal Research Branch,
Nutrition Education Division, Human Nutrition Information Service, U.S.
Department of Agriculture, Hyattsville, Maryland
Cheryl L. Damberg, M.P.H., Director of Marketing, General Health Inc.,
Washington, D.C.
Michele DeBartolo, M.P.H., R.D., Senior Clinical Research Associate,
Pharmaceutical Products Division, Abbott Laboratories, Abbott Park,
Illinois
Hector F. DeLuca, Ph.D., Department of Biochemistry, College of Agri-
culture and Life Sciences, University of Wisconsin, Madison, Wisconsin
Dominick P. DePaola, D.D.S., Ph.D., Dean, University of Medicine and
Dentistry of New Jersey, New Jersey Dental School, Newark, New Jersey
Vincent T. DeVita, Jr., M.D., Director, National Cancer Institute, Nation-
al Institutes of Health, Bethesda, Maryland
Karen Donato, M.S., R.D., Nutritionist, National Heart, Lung, and Blood
Institute, National Institutes of Health, Bethesda, Maryland
Allan L. Drash, M.D., Professor of Pediatrics, University of Pittsburgh
School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Penn-
sylvania
XXV
Mary Dufour, M.D., Chief, Epidemiology Branch, Division of Biometry
and Epidemiology, National Institute on Alcohol Abuse and Alcoholism,
Alcohol, Drug Abuse, and Mental Health Administration, Rockville,
Maryland
Harriet P. Dustan, M.D., Veterans Administration Distinguished Physi-
cian and University Distinguished Professor Emeritus, Veterans Adminis-
tration Medical Center, University of Alabama at Birmingham, Bir-
mingham, Alabama
Mary Egan, R.D., M.S., M.P.H., National Center for Education in Mater-
nal and Child Health, Georgetown University, Washington, D.C.
Shirley Ekvall, Ph.D., R.D., Professor and Chief of Nutrition Services,
University of Cincinnati and University Affiliated Cincinnati Center for
Developmental Disorders, Children's Hospital Medical Center, Cincin-
nati, Ohio
Lillian Emmons, Ph.D., R.D., Comprehensive Psychiatric Services, Inc.,
Cleveland, Ohio
Arnold Engel, M.D., Commission Officer, Medical Statistics Branch,
National Center for Health Statistics, Centers for Disease Control, Hyatts-
ville , Maryland
Frank Falkner, M.D., F.R.C.P., School of Public Health, University of
California, Berkeley, California
Marilyn E. Farrand, M.S., R.D., Public Health Nutrition, Prevention and
Demonstration Research Branch, Division of Epidemiology and Clinical
Application, National Heart, Lung, and Blood Institute, National Insti-
tutes of Health, Bethesda, Maryland
Owen Fennema, Ph.D., Department of Food Science, University of Wis-
consin at Madison, Madison, Wisconsin
John D. Femstrom, Ph.D., Professor of Psychiatry and Behavioral Neuro-
science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsyl-
vania
Willis R. Foster, M.D., Senior Staff Physician, Office of Disease Preven-
tion and Technology Transfer, National Institute of Diabetes and Digestive
and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
Judith Fradkin, M.D., Chief, Endocrine and Metabolic Diseases Programs
Branch, National Institute of Diabetes and Digestive and Kidney Diseases,
National Institutes of Health, Bethesda, Maryland
xxvi
Victor Frattali, Ph.D., Deputy Director, Division of Nutrition, Offtce of
Nutrition and Food Sciences, Center for Food Safety and Applied Nutri-
tion, Food and Drug Administration, Washington, D.C.
Robert A. Fried, M.D., Associate Professor and Director of Clinical Af-
fairs, Department of Family Medicine, University of Colorado School of
Medicine, Denver, Colorado
Edward D. Frohlich, M.D., Alton Ochsner Distinguished Scientist and
Vice President for Academic Affairs, Alton Ochsner Medical Foundation,
Staff Member, Section on Hypertensive Diseases, Ochsner Clinic, New
Orleans, Louisiana
Peter Frommer, M.D., Deputy Director, National Heart, Lung, and Blood
Institute, National Institutes of Health, Bethesda, Maryland
Margie Gallagher, Ph.D., R.D., School of Home Economics, Institute for
Coastal and Marine Resources, East Carolina University, Greenville,
North Carolina
Dian Gans, M.S., Research Assistant, Department of Nutritional Sci-
ences, University of Wisconsin at Madison, Madison, Wisconsin
Stanley M. Gam, Ph.D., Center for Human Growth and Development,
University of Michigan, Ann Arbor, Michigan
Peter Gergen, M.D., Commission Officer, Medical Statistics Branch, Na-
tional Center for Health Statistics, Centers for Disease Control, Hyatts-
ville , Maryland
Dorothy W. Gietzen, Ph.D., Assistant Research Neurophysiologist, De-
partment of Physiologic Sciences, School of Veterinary Medicine, Depart-
ment of Psychiatry, School of Medicine, University of California at Davis,
Davis, California
Susan Gilbert, M.P.A., Associate, Prospect Associates, Rockville, Mary-
land
Walter H. Glinsmann, M.D., Associate Director, Clinical Nutrition, Divi-
sion of Nutrition, Food and Drug Administration, Washington, D.C.
Vay Liang W. Go, M.D., Chairman, Nutrition Coordinating Committee,
National Institutes of Health, Bethesda, Maryland
Murray Goldstein, D.O., M.P.H., Director, National Institute of Neu-
rological and Communicative Disorders and Stroke, National Institutes of
Health, Bethesda, Maryland
xxvii
Dewitt S. Goodman, M.D., Professor of Medicine, Department of Medi-
cine, College of Physicians and Surgeons of Columbia University, New
York, New York
PhiUip Gorden, M.D., Director, National Institute of Diabetes and Di-
gestive and Kidney Diseases, National Institutes of Health, Bethesda,
Maryland
Enoch Gordis, M.D., Director, National Institute on Alcohol Abuse and
Alcoholism, Alcohol, Drug Abuse and Mental Health Administration,
Rockville , Maryland
Stephen L. Gordon, Ph.D., Director, Musculoskeletal Diseases Program,
National Institute of Arthritis and Musculoskeletal and Skin Diseases,
National Institutes of Health, Bethesda, Maryland
Gilman D. Grave, M.D., Chief, Endocrinology, Nutrition, and Growth
Branch, National Institute of Child Health and Human Development,
National Institutes of Health, Bethesda, Maryland
Jesse F. Gregory III, Ph.D., University of Florida, Food Science and
Nutrition Department, Gainesville, Florida
Joan Gussow, Ed.D., Mary Swartz Rose Professor of Nutrition and Edu-
cation, Department of Nutrition and Education, Teachers College, Colum-
bia University, New York
Wilbur Hadden, M.A., Chief, Programming Staff, National Center for
Health Statistics, Centers for Disease Control, Hyattsville, Maryland
Evan Hadley, M.D., Chief, Geriatrics Branch, National Institute on
Aging, National Institutes of Health, Bethesda, Maryland
Carole Haines, M.P.H., Data Analysis Coordinator, National Heart,
Lung, and Blood Institute, National Institutes of Health, Bethesda, Mary-
land
Judith G. Hallfrisch, Ph.D., Senior Staff Fellow, Metabolism Section of
the Gerontology Research Center, National Institute on Aging, National
Institutes of Health, Bethesda, Maryland
Charles H. Halsted, M.D., Ph.D., Chief, Division of Clinical Nutrition,
and Professor of Internal Medicine, School of Medicine, University of
California at Davis, Davis, California
Linda Harris, Ph.D., Special Assistant, Gflice of Disease Prevention and
Health Promotion, Washington, D.C.
. . .
XXVlll
Tamara Harris, M.D., Service Fellow, Office of Analysis and Epidemiolo-
gy Program, National Center for Health Statistics, Centers for Disease
Control, HyattsviUe, Maryland
John N. Hathcock, Ph.D., Chief, Experimental Nutrition Branch, Division
of Nutrition, Food and Drug Administration, Washington, D.C.
Maureen Henderson, M.D., Cancer Prevention Research Program, Fred
Hutchinson Cancer Research Center, Seattle, Washington
Stephen P. Heyse, M.D., Director, Disease Prevention, Epidemiology and
Clinical Applications, National Institute of Arthritis and Musculoskeletal
and Skin Diseases, National Institutes of Health, Bethesda, Maryland
Jules Hirsch, M.D., Professor and Senior Physician, Rockefeller Univer-
sity, New York, New York
Gladys Hirshman, M.D., Director, Chronic Renal Disease Program, Na-
tional Institute of Diabetes and Digestive and Kidney Diseases, National
Institutes of Health, Bethesda, Maryland
Peter R. Holt, M.D., Chief, Division of Gastroenterology, Professor of
Medicine, College of Physicians and Surgeons, St. Luke's Hospital, New
York, New York
Steven S. Hotta, M.D., Ph.D., Medical Gflicer, Clinical Nutrition Branch,
Division of Nutrition, Food and Drug Administration, Washington, D.C.
Anastacio M. Hoyumpa, M.D., Professor of Medicine, Division of Gas-
troenterology and Nutrition, University of Texas Health Science Center,
San Antonio, Texas
Van S. Hubbard, M.D., Ph.D., Director, Nutritional Sciences Branch,
National Institute of Diabetes and Digestive and Kidney Diseases, Nation-
al Institutes of Health, Bethesda, Maryland
Sandra Huckaby, R.N., M.S.N., Special Assistant, Maternal and Infant
Health Branch, Bureau of Maternal and Child Health and Resources
Development, Health Resources and Services Administration, RockviUe,
Maryland
James C. Hunt, M.D., Chancellor, University of Tennessee, Memphis,
Tennessee
Vince L. Hutchins, M.D., M.P.H., Deputy Director, Bureau of Maternal
and Child Health and Resources Development, Health Resources and
Services Administration, Rockville, Maryland
xxix
William T. Jan+, Ph.D., Professor of Health Education, Department of
Preventive Medicine, School of Medicine, Loma Linda University, Loma
Linda, California
Clifford Johnson, M.S.P.H., Chief, Nutrition Statistics Branch, National
Center for Health Statistics, Centers for Disease Control, Hyattsville,
Maryland
Norman Kaplan, M.D., Professor of Internal Medicine, University of
Texas Health Science Center, Dallas, Texas
Gerald T. Keusch, M.D., Professor of Medicine, Department of Medicine,
New England Medical Center, Boston, Massachusetts
Matthew Kinnard, Ph.D., Health Scientist Administrator, National Insti-
tute of Dental Research, National Institutes of Health, Bethesda, Mary-
land
Samuel Korper, Ph.D., Associate Director, Offtce of Planning, Analysis,
and Communications, National Institute on Aging, National Institutes of
Health, Bethesda, Maryland
David Kritchevsky, Ph.D., Associate Director of Anatomy and Biology,
Wistar Institute, Philadelphia, Pennsylvania
Robert Kuczmarksi, M.S.P.H., M.P.H., Dr.P.H., R.D., Health Statisti-
cian, Nutrition Statistics Branch, National Center for Health Statistics,
Centers for Disease Control, Hyattsville, Maryland
William Lands, Ph.D., Department of Biochemistry, University of Illinois
at Chicago, Chicago, Illinois
Lynn A. Larsen, Ph.D., Associate Director, Program Development, Divi-
sion of Nutrition, Office of Nutrition and Food Sciences, Center for Food
Safety and Applied Nutrition, Food and Drug Administration, Washington,
D.C.
Reva C. Lawrence, M.P.H., Epidemiologist, Data Systems, Program Of-
ficer, National Institute of Arthritis and Musculoskeletal and Skin Dis-
eases, National Institutes of Health, Bethesda, Maryland
Claude Lenfant, M.D., Director, National Heart, Lung, and Blood Insti-
tute, National Institutes of Health, Bethesda, Maryland
Gilbert A. Leveille, Ph.D., Staff Vice President, NABISCO Brands, Inc.,
East Hanover, New Jersey
xxx
Ephraim Y. Levin, M.D., Medical Officer, National Institute of Child
Health and Human Development, National Institutes of Health, Bethesda,
Maryland
Christine J. Lewis, Ph.D., R.D., Chief, Experimental Clinical Research
Section, Division of Nutrition, Oflice of Nutrition and Food Sciences,
Center for Food Safety and Applied Nutrition, Food and Drug Administra-
tion, Washington, D.C.
Charles S. Lieber, M.D., Director, Alcohol Research and Treatment Cen-
ter, Chief, Section of Liver Disease and Nutrition, Bronx Veterans Admin-
istration Medical Center, Professor of Medicine and Pathology, Mount
Sinai School of Medicine, New York, New York
Jane Lin Fu, M.D., Acting Chief, Genetic Services Branch, Bureau of
Maternal and Child Health and Resources Development, Health Resources
and Services Administration, Rockville, Maryland
Harald Lee, D.D.S., Director, National Institute of Dental Research,
National Institutes of Health, Bethesda, Maryland
Anne Looker, Ph.D., R.D., Health Statistician, Nutrition Statistics
Branch, National Center for Health Statistics, Centers for Disease Con-
trol, Hyattsville, Maryland
Susan K. Maloney, M.H .S., Director, Health Communication Staff, Office
of Disease Prevention and Health Promotion, Washington, D.C.
Alvin Mauer, M.D., University of Tennessee, Division of Hematology/
Oncology, Memphis, Tennessee
Donald B. McCormick, Ph.D., Chairman, Department of Biochemistry,
Emory University School of Medicine, Atlanta, Georgia
Gardner C. McMillan, M.D., Division of Heart and Vascular Diseases,
National Heart, Lung, and Blood Institute, National Institutes of Health,
Bethesda, Maryland
Marilyn McMillen, Ph.D., Statistician, Surveillance and Operations Re-
search Section, National Cancer Institute, National Institutes of Health,
Bethesda, Maryland
Laura McNally, R.D., M.P.H., Nutrition Specialist, Child and Adolescent
Primary Care Services Branch, Bureau of Maternal and Child Health and
Resources Development, Health Resources and Services Administration,
Rockville, Maryland
xxxi
Marsel Mesulam, M.D., Professor of Neurology, Harvard Medical School,
Director, Division of Neuroscience and Behavioral Neurology, Beth Israel
Hospital, Boston, Massachusetts
Esteban Mezey, M.D., Professor of Medicine, Johns Hopkins Hospital,
Baltimore, Maryland
Angela D. Mickalide, Ph.D., Staff Coordinator, U.S. Preventive Services
Task Force, Office of Disease Prevention and Health Promotion, Washing-
ton, D.C.
William E. Mitch, M.D., Renal Division, Emory University School of
Medicine, Atlanta, Georgia
Elaine R. Monsen, Ph.D., R.D., University of Washington, Seattle, Wash-
ington
Steven R. Moore, M.P.H., Associate Chief of Staff, Office of the Surgeon
General, Rockville, Maryland
Hamish N. Munro, M.D., D.Sc., Senior Scientist, USDA Human Nutri-
tion Research Center on Aging, Tufts University, Boston, Massachusetts
Juan M. Navia, Ph.D., Professor and Chairman, Department of Public
Health Sciences, Schools of Public Health and Dentistry, University of
Alabama at Birmingham, Birmingham, Alabama
Buford L. Nichols, Jr., M.D., Children's Nutrition Research Laboratory,
Baylor School of Medicine, Houston, Texas
Phillip Nieburg, M.D., M.P.H., Medical Epidemiologist, Division of Nutri-
tion, Centers for Disease Control, Atlanta, Georgia
Daniel W. Nixon, M.D., Associate Director, Cancer Prevention Research
Program, National Cancer Institute, National Institutes of Health, Bethes-
da, Maryland
Marie U. Nylen, D.D.S., Dr. Odont. h.c., Director, Extramural Program,
National Institute of Dental Research, National Institutes of Health, Be-
thesda, Maryland
Carole A. Palmer, M.Ed., R.D., Associate Professor and Division Co-
Chairman, Division of Nutrition and Prevention Dentistry, Tufts Univer-
sity School of Medicine, Boston, Massachusetts
xxxii
Eugene Passamani, M.D., Director, Division of Heart and Vascular Dis-
eases, National Heart, Lung, and Blood Institute, National Institutes of
Health, Bethesda, Maryland
Penelope Pollard, M.S., M.B.A., Senior Research Associate, National
Health Policy Forum, Washington, D.C.
Donna V. Porter, Ph.D., R.D., Specialist in Life Sciences, Science Policy
Research Division, Congressional Research QIXce, Washington, D.C.
Roger J. Porter, M.D., Deputy Director, National institute of Neurological
and Communicative Disorders and Stroke, National Institutes of Health,
Bethesda, Maryland
Barbara Posner, D.P.H., R-D., Associate Professor and Director, Graduate
Nutrition Division, Boston University, Boston, Massachusetts
Ann Prendergast, R.D., M.P.H., Chief Nutritionist, Habilitative Services
Branch, Bureau of Maternal and Child Health and Resources Develop-
ment, Health Resources and Services Administration, Rockville, Mary-
land
Jeanne I. Rader, Ph.D., Chief, Nutrient Toxicity Section, Experimental
Nutrition Branch, Division of Nutrition, Food and Drug Administration,
Washington, D.C.
Edward Roccella, Ph.D., M.P.H., Program Coordinator, National High
Blood Pressure Education Program, National Heart, Lung, and Blood
Institute, National Institutes of Health, Bethesda, Maryland
Daphne A. Roe, M.D., Professor, Division of Nutritional Sciences, Cornell
University, Ithaca, New York
Quinton Rogers, Ph.D., Department of Physiological Sciences, School of
Veterinary Medicine, University of California at Davis, Davis, California
Daniel Rudman, M.D., Associate Chief of Staff, Geriatric Medicine, North
Chicago Veterans Administration Medical Center, North Chicago, Illinois
Robert Russell, M.D., USDA Human Nutrition Research Center on Aging
at Tufts University, Boston, Massachusetts
Anna A. Sandberg, Dr.P.H., Coordinator, Clinical Trial, Kidney-Urology
Branch, National Institute of Diabetes and Digestive and Kidney Diseases,
National Institutes of Health, Bethesda, Maryland
. . .
xxx111
Harold H. Sandstead, M.D., Department of Preventive Medicine and
Community Health, University of Texas Medical Branch, Galveston,
Texas
Howerde Sauberlich, Ph.D., Department of Nutrition Science, University
of Alabama, University Station, Alabama
Christopher Sempos, Ph.D., Health Statistician, Nutrition Statistics
Branch, National Center for Health Statistics, Centers for Disease Con-
trol, Hyattsville, Maryland
Zekin Shakhashiri, M.S., M.D., M.P.H., Senior Medical Advisor, National
Institute of Neurological and Communicative Disorders and Stroke, Na-
tional Institutes of Health, Bethesda, Maryland
Lawrence E. Shulman, M.D., Ph.D., Director, National Institute of Arthri-
tis and Musculoskeletal and Skin Diseases, National Institutes of Health,
Bethesda, Maryland
Robert Silverman, M.D., Ph.D., Chief, Diabetes Programs Branch, Na-
tional Institute of Diabetes and Digestive and Kidney Diseases, National
Institutes of Health, Bethesda, Maryland
Christine Hamilton Smith, Ph.D., R.D., Home Economics Department,
Food Science and Nutrition, California State University at Northridge,
Northridge, California
Dorothy D. Sogn, M.D., Chief, Asthma and Allergy Branch, Immunology,
Allergic and Immunologic Diseases Program, National Institute of Allergy
and Infectious Diseases, National Institutes of Health, Bethesda, Mary-
land
David A.T. Southgate, Ph.D., AFRC Institute of Food Research, Norwich
Laboratory, Norfolk, United Kingdom
Reynold Spector, M.D., Executive Director, Merck Sharp & Dohme Re-
search Laboratories, Rahway, New Jersey
Judith S. Stem, Sc.D., University of California at Davis, Davis, California
Eugene Streicher, Ph.D., Director, Division of Fundamental Neurosci-
ences, National Institute of Neurological and Communicative Disorders
and Stroke, National Institutes of Health, Bethesda, Maryland
Helene Swenerton, Ph.D., Nutritionist, Cooperative Extension, Depart-
ment of Nutrition, University of California at Davis, Davis, California
xxxiv
Jean K. Tews, Ph.D., Department of Biochemistry, University of Wiscon-
sin at Madison, Madison, Wisconsin
Jeanne L. Tillotson, R.D., M.A., Crofton, Maryland
Phillip P. Toskes, M.D., Professor of Medicine and Director, Division of
Gastroenterology, Hepatology and Nutrition, University of Florida Col-
lege of Medicine and Gainesville Veterans Administration Medical Center,
Gainesville, Florida
Pelagia Turyn-Einhom, M.D., Medical OfIicer, Clinical Nutrition Branch,
Division of Nutrition, Office of Nutrition and Food Sciences, Center for
Food Safety and Applied Nutrition, Food and Drug Administration, Wash-
ington, D.C.
Emestine Vanderveen, Ph.D., Associate Director for AIDS, Division of
Clinical Research, National Institute on Drug Abuse, Alcohol, Drug
Abuse, and Mental Health Administration, Rockville, Maryland
John E. Vanderveen, Ph.D., Director, Division of Nutrition, Food and
Drug Administration, Washington, D.C.
John Wallingford, Ph.D., Nutritionist, Clinical Nutrition Branch, Division
of Nutrition, Office of Nutrition and Food Sciences, Center for Food Safety
and Applied Nutrition, Food and Drug Administration, Washington, D.C.
Donald M. Watkin, A.B., M.D., M.P.H., Manager, Occupational Health
Division, Office of Aviation Medicine, Federal Aviation Administration,
U.S. Department of Transportation, and Research Professor, Department
of Medicine, School of Medicine and Health Sciences, The George Wash-
ington University, Washington, D.C.
Richard Weindruch, Ph.D., Health Scientist Administrator, National Insti-
tute on Aging, National Institutes of Health, Bethesda, Maryland
Gerald Wheeler, Commission Officer, Division of Health Examination
Statistics, National Center for Health Statistics, Centers for Disease Con-
trol, Hyattsville, Maryland
Philip L. White, Sc.D., Wilmette, Illinois, Director, Division of Applied
Medical Sciences, American Medical Association, Chicago, Illinois (Re-
tired)
T. Franklin Williams, M.D., Director, National Institute on Aging, Nation-
al Institutes of Health, Bethesda, Maryland
XXXV
David E Williamson, M.S., Ph.D., Analytic Epidemiologist, Centers for
Disease Control, Atlanta, Georgia
Myron Winick, M.D., R.R. Williams Professor of Nutrition and Pediatrics,
Columbia University College of Physicians and Surgeons, New York, New
York
Deborah Winn, Ph.D., Epidemiologist, Survey Planning and Development
Branch, National Center for Health Statistics, Centers for Disease Con-
trol, Hyattsville, Maryland
Maxwell M. Wintrobe, M.D., Ph.D., D.Sc., Distinguished Professor of
Medicine, University of Utah Medical School, Salt Lake City, Utah
Elisabeth I? Wirick, Food, Nutrition, and Dietetics, College of Health and
Human Services, University of Northern Colorado, Greeley, Colorado
Eleanor A. Young, Ph.D., R.D., L.D., Professor, Department of Medicine,
Division of Gastroenterology and Nutrition, University of Texas Health
Science Center at San Antonio, San Antonio, Texas
William J. Zukel, M.D., Deputy Director, Division of Heart and Vascular
Diseases, National Heart, Lung, and Blood Institute, National Institutes of
Health, Bethesda, Maryland
The editors gratefully acknowledge the contributions of the following
staff members and others who assisted in the preparation of this
Report:
o Office of Disease Prevention and Health Promotion
Nancy Chapman, R.D., M.P.H., President, N. Chapman Associates,
Washington, D.C.
Mary Jo Deering, Ph.D., Publications Manager
James A. Harrell, M.A., Deputy Director
Susan K. Maloney, M.H.S., Director, Health Communication Staff
David G. Schardt, M.S., Ph.D., Nutrition Consultant, Nutrition
Media Network, Washington, D.C.
Marilyn K. Schulenberg, Staff Assistant
Maureen Sullivan, M.P.H., M.I.A., Program Analyst, U.S. Food
and Drug Administration, New York, New York
xxxvi
Herbert Szeto, Intern, Nutrition Policy Staff
Sara L. White, M.S., Health Promotion Research Associate, Health
Communication Staff
o Technical Resources, Inc.
Joanna Fringer, M.A., Program Manager
Jeffrey Baughman, Graphic Artist
Colleen Bolton, Graphic Artist
Diane Cannon, Graphic Artist
James Dofflemyer, Graphic Artist
Dana Donofrio, Word Processor
Robin Fagan, Graphic Artist
Margaret Leahy, Editor
Cathy Merritt, Word Processor
Laura Pancoast, Word Processing Supervisor
Cherie Phillips, Graphic Artist
Theodora Radcliffe, Proofreader
William Rhodes, Graphic Artist
Joan Saunders, Writer/Editor
Channah Springer, M . F. A., Proofreader
David Tran, Information Specialist
o TRITON, Inc.
Clarence Johnson, Communications Manager
John Borstel, Senior Graphics Editor
Sharon Greenspan, Graphics Assistant
xxxvii
Summary and Recommendations
This Report addresses the substantial impact of daily dietary patterns on
the health of Americans. Good health does not always come easily. It is the
product of complex interactions among environmental. behavioral, social,
and genetic factors. Some of these are, for practical purposes, beyond
persona1 control. But there are many ways in which each of us can
influence our chances for good health through the daily choices we make.
In recent years, scientific investigations have produced abundant informa-
tion on the ways persona1 behavior affects health. This information can
help us decide whether to smoke, when and how much to drink, how far to
walk or climb stairs, whether to wear seat belts, and how or whether to
engage in any other activity that might alter the risk of incurring disease or
disability. For the two out of three adult Americans who do not smoke and
do not drink excessively, one personal choice seems to influence long-term
health prospects more than any other: what we eat.
Food sustains us, it can be a source of considerable pleasure, it is a
reflection of our rich social fabric and cultural heritage, it adds valued
dimensions to our lives. Yet what we eat may affect our risk for several of
the leading causes of death for Americans, notably, coronary heart dis-
ease, stroke, atherosclerosis, diabetes, and some types of cancer. These
disorders together now account for more than two-thirds of all deaths in the
United States.
Undernutrition remains a problem in several parts of the world, as well as
for certain Americans. But for most of us the more likely problem has
become one of overeating-too many calories for our activity levels and an
imbalance in the nutrients consumed along with them. Although much is
still uncertain about how dietary patterns protect or injure human health,
enough has been learned about the overall health impact of the dietary
patterns now prevalent in our society to recommend significant changes in
those patterns.
This first Surgeon General's Report on Nutrition and Health offers com-
prehensive documentation of the scientific basis for the recommended
dietary changes. Through the extensive review contained in its chapters,
the Report examines in detail current knowledge about the relationships
among specific dietary practices and specific disease conditions and sum-
1
O Nutrition and Health
marizes the implications of this information for individual food choices,
public health policy initiatives, and further research. The Report's main
conclusion is that overconsumption of certain dietary components is now a
major concern for Americans. While many food factors are involved, chief
among them is the disproportionate consumption of foods high in fats, often
at the expense of foods high in complex carbohydrates and fiber that may be
more conducive to health. A list of the key recommendations based on the
evidence presented in the Report is provided in Table 1.
Magnitude of the Problem
Diet has always had a vital influence on health. Until as recently as the
1940's, diseases such as rickets, pellagra, scurvy, beriberi, xerophthalmia,
andgoiter (caused by lack of adequate dietary vitamin D, niacin, vitamin C,
thiamin, vitamin A, and iodine, respectively).were prevalent in this coun-
try and throughout the world. Today, thanks to an abundant food supply,
fortification of some foods with critical trace nutrients, and better methods
for determining and improving.the nutrient content of foods, such "deti-
ciency" diseases have been virtually eliminated in developed countries.
For example, the introduction of iodized salt in the 1920's contributed
greatly to eliminating iodine-deficiency goiter as a public health problem in
the United States. Similarly, pellagra disappeared subsequent to the dis-
covery of the dietary causes of this disease. Nutrient deficiencies are
reported rarely in the United States, and the few cases of protein-energy
malnutrition that are listed annually as causes of death generally occur as a
secondary result of severe illness or injury, child neglect, the problems of
the house-bound aged, premature birth, alcoholism, or some combination
of these factors.
As the diseases of nutritional deficiency have diminished; they have been
replaced by diseases'of dietary excess and imbalance-problems that now
rank among the leading causes of illness and death in the United States,
touch the lives of most Americans, and generate substantial health care
costs. Table 2, for example, lists the 10 leading causes of death in the
United States in 1987.
In addition to the five of these causes that scientific studies have associated
with diet (coronary heart disease, some-types of cancer, stroke, diabetes
mellitus, and atherosclerosis), another three-cirrhosis of the liver, acci-
dents, and suicides-have been associated With excessive alcohol intake.
2
Summary and Recommendations O
Table 1
Recommendations
Issues for Most People:
o Furs and cholesterol: Reduce consumption of fat (especially saturated fat) and
cholesterol. Choose foods relatively low in these substances, such as vegeta-
bles, fruits, whole gram foods, fish, poultry, lean meats. and low-fat dairy
products. Use food preparation methods that add little or no fat.
o Energy and weight control: Achieve and maintain a desirable body weight. To
do so, choose a dietary pattern in which energy (caloric) intake is consistent
with energy expenditure. To reduce energy intake, limit consumption of foods
relatively high in calories, fats, and sugars, and minimize alcohol consump-
tion. Increase energy expenditure through regular and sustained physical ac-
tivity.
o Complex carbohydrates andfiber: Increase consumption of whole grain foods
and cereal products, vegetables (including dried beans and peas), and fruits.
o Sodium: Reduce intake of sodium by choosing foods relatively low in sodium
and limiting the amount of salt added in food preparation and at the table.
o Alcohol: To reduce the risk for chronic disease, take alcohol only in modera-
tion (no more than two drinks a day), if at all. Avoid drinking any alcohol be-
fore or while driving, operating machinery, taking medications, or engaging in
any other activity requiring judgment. Avoid drinking alcohol while pregnant.
Other Issues for Some People:
o Fluoride: Community water systems should contain fluoride at optimal levels
for prevention of tooth decay. If such water is not available, use other appro-
priate sources of fluoride.
o Sugars: Those who are particularly vulnerable to dental caries (cavities). espe-
cially children, should limit their consumption and frequency of use of foods
high in sugars.
o Calcium: Adolescent girls and adult women should increase consumption of
foods high in calcium, including low-fat dairy products.
o Iron: Children, adolescents, and women of childbearing age should be sure to
consume foods that are good sources of iron, such as lean meats, fish, certain
beans, and iron-enriched cereals and whole grain products. This issue is of
special concern for low-income families.
0 Nutrition and Health
Table 2
Estimated Total Deaths and Percent of Total Deaths for the
10 Leading Causes of Death: United States, 1987
Percent
of Total
Rank Cause of Death Number Deaths
la Heart diseases 759,400 35.7
(Coronary heart disease) (511,700) (24.1)
(Other heart disease) (247,700) (11.6)
2a Cancers 476,700 22.4
3a Strokes 148,700 7.0
4b Unintentional injuries 92,500
(Motor vehicle) W8O'J (E,
(All others) (45,700)
5 Chronic obstructive lung diseases 78,000 %'
6 Pneumonia and influenza 68,600 3:2
78 Diabetes mellitus 37,800 1.8
8b Suicide 29,600 1.4
9b Chronic liver disease and cirrhosis 26,000 1.2
10s Atherosclerosis 23,100 1.1
. . . AU causes 2,125,100
causes of death in which diet plays a part.
Wauses of death in which excessive alcohol consumption plays a part.
100.0
Source: National Center for Health Statistics, Monthly Vital Statistics Report, vol. 37, no.
1 ,April25,sticsReport,vol.37, no.
1, April 25,1989.
Although the precise proportion attributable to diet is uncertain, these
eight conditions accounted for nearly 1.5 million of the 2.1 million total
deaths in 1987. Dietary excesses or imbalances also contribute to other
problems such as high blood pressure, obesity, dental diseases, os-
teoporosis, and gastrointestinal diseases. Together, these diet-related con-
ditions inflict a substantial burden of illness on Americans. For example:
o Coronary Heart Disease. Despite the recent sharp decline in the death
rate from this condition, coronary heart disease still accounts for the
largest number of deaths in the United States. More than 1.25 million
heart attacks occur each year (two-thirds of them in men), and more
than 500,000 people die as a result. In 1985, illness and deaths from
coronary heart disease cost Americans an estimated $49 billion in
direct health care expenditures and lost productivity.
o Stroke. Strokes occur in about 500,000 persons per year in the United
States, resulting in nearly 150,000 deaths in 1987 and long-term dis-
ability for many individuals. Approximately 2 million living Americans
suffer from stroke-related disabilities, at an estimated annual cost of
more than $11 billion.
4
Summary and Recommendations 0
o High Blood Pressure. High blood pressure (hypertension) is a major
risk factor for both heart disease and stroke. Almost 58 million people
in the United States have hypertension, including 39 million who are
under age 65. The occurrence of hypertension increases with age and is
higher for black Americans (of which 38 percent are hypertensive)
than for white Americans (29 percent).
o Cancer. More than 475,000 persons died of cancer in the United States
in 1987, making it the second leading cause of death in this country.
During the same period, more than 900,000 new cases of cancer
occurred. The costs of cancer for 1985 have been estimated to be $22
billion for direct health care, $9 billion in lost productivity due to
treatment or disability, and $41 billion in lost productivity due to
premature mortality, for a total cost of $72 billion.
o Diabetes Meflitus. Approximately 11 million Americans have diabe-
tes, but almost half of them have not been diagnosed. In addition to the
nearly 38,000 deaths in 1987 attributed directly to this condition,
diabetes also contributes to an estimated 95,000 deaths per year from
associated cardiovascular and kidney complications. In 1985, diabetes
was estimated to cost $13.8 billion per year, or about 3.6 percent of
total health care expenses.
o Obesity. Obesity affects approximately 34 million adults ages 20 to 74
years in the United States, with the highest rates observed among the
poor and minority groups. Obesity is a risk factor for coronary heart
disease, high blood pressure, diabetes, and possibly some types of
cancer as well as other chronic diseases.
o Osteoporosis. Approximately 15 to 20 million Americans are affected
by osteoporosis, which contributes to some 1.3 million bone fractures
per year in persons 45 years and older. One-third of women 65 years
and older have vertebral fractures. On the basis of x-ray evidence, by
age 90 one-third of women and one-sixth of men will have suffered hip
fractures, leading to death in 12 to 20 percent of those cases and to
long-term nursing care for many who survive. The total costs of
osteoporosis to the U.S. economy were estimated to be $7 to $10
billion in 1983.
o Dental Diseases. Dental caries and periodontal disease continue to
affect a large proportion of Americans and cause substantial pain,
restriction of activity, and work loss. Although dental caries among
children, as well as some forms of adult periodontal disease, appear to
be declining, the overall prevalence of these conditions imposes a
substantial burden on Americans. The costs of dental care were esti-
mated at $21.3 billion in 1985.
5
O Nutrition and Health
o Diverticular Disease. Because most persons with diverticular disease
do not have symptoms, the true prevalence of this condition is un-
known. Frequency increases with age, and up to 70 percent of people
between the ages of 40 and 70 may be affected. In 1980, diverticulosis
was accountable for some 200,000 hospitalizations.
In assessing the role that diet might play in prevention of these conditions,
it must be understood that they are caused by a combination (and interac-
tion) of multiple environmental, behavioral, social, and genetic factors.
The exact proportion that can be attributed directly to diet is uncertain.
Although some experts have suggested that dietary factors overall are
responsible for perhaps a third or more of all cases of cancer, and similar
estimates have been made for coronary heart disease, such suggestions are
based on interpretations of research studies that cannot completely dis-
tinguish dietary from genetic, behavioral, or environmental causes.
We know, for example, that cigarette smoking exerts a powerful influence
on the occurrence of both coronary heart disease and some types of cancer.
We also know that some people are genetically predisposed to coronary
heart disease, stroke, and diabetes and that the interaction of genetic
predisposition with dietary patterns is an important determinant of individ-
ual risk. For these reasons, it is not yet possible to determine the propor-
tion of chronic diseases that could be reduced by dietary changes. None-
theless, it is now clear that diet contributes in substantial ways to the
development of these diseases and that modification of diet can contribute
to their prevention. The magnitude of the health and economic cost of diet-
related disease suggests the importance of the dietary changes suggested.
This Report reviews these issues in detail.
Nature of the Evidence
Whereas centuries of clinical observations and decades of basic and
clinical research prove that dietary deficiencies of single, identifiable nu-
trients can cause disease, research on the relationship of dietary excesses
and imbalances to chronic disease yields results that rarely provide such
direct proof of causality. Instead, investigators must piece together various
kinds of information from several kinds of sources. Nevertheless, the
quantity of current animal, laboratory, clinical, and epidemiologic evi-
dence that associates dietary excesses and imbalances with chronic dis-
ease is substantial and, when evaluated according to established princi-
ples, compelling.
Scientists must often draw inferences about the relationships between
dietary factors and disease from laboratory animal studies or human meta-
6
Summary and Recommendations O
bolic and population studies that approach the issues indirectly. Data
sources for such human studies include clinical and laboratory measure-
ments of physiologic indicators of nutritional status or risk factors, as well
as dietary intake data estimated for populations or individuals. Epi-
demiologic studies using these data compare dietary intake and disease
rates in different countries or in defined groups within the same country.
Interpretations of animal studies are limited by uncertainties about their
applicability to people. Clinical, laboratory, and dietary intake studies can
provide useful information, but each has limitations. Currently available
clinical and laboratory measurements reveal only a small part of the
complex physiological responses to diet, and they may reflect past rather
than current nutritional status. Dietary surveys depend on accurate recall
of the types and portion sizes of consumed foods as well as on the assump-
tion that the food intake during any one period represents typical intake.
Reported intake, however, is not always accurate, and intake reported for
a given period may differ significantly from that typical of longer time
periods. Dietary intake data provide useful indicators for populations, but
even when an association or correlation between a dietary factor and a
disease is observed, it is often ditllcult to prove that the dietary factor is an
actual or sole cause of that disease.
This difference between association and causation is basic to understand-
ing the scientific evidence that links diet to chronic disease. Uncertainties
in the ability to determine causation have sometimes made it difficult to
achieve consensus on appropriate public health nutrition policies. Estab-
lished principles require evaluation of the supporting evidence for a given
association between a dietary factor and a disease on the basis of its
consistency, strength, specificity, and biological plausibility. The evidence
showing that dietary intake of saturated fat raises blood cholesterol, which
in turn increases the chance of coronary heart disease, illustrates this
point. The similarity in results from laboratory, clinical, and epidemiologic
research, the apparent relationship between dose and effect in these stud-
ies, the observations that the increase in blood cholesterol level is ~p~ifk
to saturated fatty acids but not to other types, and the biological plausibility
of explanations for the observations, when taken together, provide consid-
erable support for concluding that the association is causal, at least for
some individuals.
For some of the other diseases reviewed in this Report, the available
evidence is less complete and less consistent. Nevertheless, much evi-
dence supports credible associations between a dietary pattern of excesses
u Nutrition and Health
and imbalances and several important chronic diseases. These associa-
tions, in turn, suggest that the overall health of Americans could be
improved by a few specific but fundamental dietary changes.
Key Findings and Recommendations
Even though the results of various individual studies may be inconclusive,
the preponderance of the evidence presented in the Report's comprehen-
sive scientific review substantiates an association between dietary factors
and rates of chronic diseases. In particular, the evidence suggests strongly
that a dietary pattern that contains excessive intake of foods high in
calories, fat (especially saturated fat), cholesterol, and sodium, but that is
low in complex carbohydrates and fiber, is one that contributes signifi-
cantly to the high rates of major chronic diseases among Americans. It also
suggests that reversing such dietary patterns should lead to a reduced
incidence of these chronic diseases.
This Surgeon General's Report on Nutrition and Health provides a com-
prehensive review of the most important scientific evidence in support of
current Federal nutrition policy as stated in the Dietary Guidelines for
Americans. These Guidelines, issued jointly by the Department of Agri-
culture and the Department of Health and Human Services, recommend:
o Eat a variety of foods.
o Maintain desirable weight.
o Avoid too much fat, saturated fat, and cholesterol.
o Eat foods with adequate starch and fiber.
o Avoid too much sugar.
o Avoid too much sodium.
o If you drink alcoholic beverages, do so in moderation.
Evidence presented in this Report expands the focus of these seven guide-
lines and provides considerable insight into priorities. Clearly emerging as
the primary priority for dietary change is the recommendation to reduce
intake of total fats, especially saturated fat, because of their relationship to
development of several important chronic disease conditions. Because
excess body weight is a risk factor for several chronic diseases, mainte-
nance of desirable weight is also an important public health priority.
Evidence further supports the recommendation to consume a dietary
pattern that contains a variety of foods, provided that these foods are
generally low in calories, fat, saturated fat, cholesterol, and sodium.
8
Summary and Recommendations O
Taken together, the recommendations in this Report promote a dietary
pattern that emphasizes consumption of vegetables, fruits, and whole grain
products-foods that are rich in complex carbohydrates and fiber and
relatively low in calories-and of fish, poultry prepared without skin, lean
meats, and low-fat dairy products selected to minimize consumption of
total fat, saturated fat, and cholesterol.
The evidence presented in this Report suggests that such overall dietary
changes will lead to substantial improvements in the nutritional quality of
the American diet. Consuming a higher proportion of calories from fruits,
vegetables, and grains may lead to a modest reduction in protein intake for
some people, but this reduction is unlikely to impair nutritional status.
Average levels of protein consumption in the United States, 60 grams per
day for women and 90 grams per day for men, are well above the National
Research Council's recommendations of 44 and 56 grams per day, respec-
tively .
The evidence also suggests that most Americans generally need not con-
sume nutrient supplements. An estimated 40 percent of Americans con-
sume supplemental vitamins, minerals, or other dietary components at an
annual cost of more than $2.7 billion. Although nutrient supplements are
usually safe in amounts corresponding to the Recommended Dietary Al-
lowances (and such Allowances are set to ensure that the nutrient needs of
practically all the population are met), there are no known advantages to
healthy people consuming excess amounts of any nutrient, and amounts
greatly exceeding recommended levels can be harmful. For example, some
nutrients such as selenium have a narrow range of safe level of intake.
Toxicity has been reported for most minerals and trace elements, as well as
some vitamins, indicating that excessive supplementation with these sub-
stances can be hazardous.
Finally, some recommendations for dietary change apply broadly to the
general public whereas others apply only to specific population groups.
These major findings and recommendations of The Surgeon General's
Report on Nutrition and Health are noted below.
Issues for Most People
0 Fats andcholesterol: Reduce consumption of fat (especially saturated fat)
and cholesterol. Choose foods relatively low in these substances, such as
vegetables, fruits, whole grain foods, bh, poultry, lean meats, and low-
fat dairy products. Use food preparation methods that add little or no
fat.
9
0 Nutrition and Health
High intake of total dietary fat is associated with increased risk for obesity,
some types of cancer, and possibly gallbladder disease. Epidemiologic,
clinical, and animal studies provide strong and consistent evidence for the
relationship between saturated fat intake, high blood cholesterol, and
increased risk for coronary heart disease. Conversely, reducing blood
cholesterol levels reduces the risk for death from coronary heart disease.
Excessive saturated fat consumption is the major dietary contributor to
total blood cholesterol levels. Dietary cholesterol raises blood cholesterol
levels, but the effect is less pronounced than that of saturated fat. While
polyunsaturated fatty acid consumption, and probably monounsaturated
fatty acid consumption, lowers total blood cholesterol, the precise effects
of specific fatty acids are not well defined.
Dietary fat contributes more than twice as many calories as equal quanti-
ties (by weight) of either protein or carbohydrate, and some studies indi-
cate that diets high in total fat are associated with higher obesity rates. In
addition, there is substantial, although not yet conclusive, epidemiologic
and animal evidence in support of an association between dietary fat intake
and increased risk for cancer, especially breast and colon cancer. Similar-
ly, epidemiologic studies suggest an association between gallbladder dis-
ease, excess caloric intake, high dietary fat, and obesity. More precise
conclusions about the role of dietary fat await the development of im-
proved methods to distinguish among the contributions of the high-calorie,
high-fat, and low-fiber components of current American dietary patterns.
At present, dietary fat accounts for about 37 percent of the total energy
intake of Americans-well above the upper limit of 30 percent recom-
mended by the American Heart Association and the American Cancer
Society, and above the percent consumed by many societies, such as
Mediterranean countries, Japan, and China, for example, where coronary
heart disease rates are much lower than those observed in the United
States. Consumption of saturated fat and cholesterol is also substantially
higher among many Americans than levels recommended by several expert
groups.
The major dietary sources of fat in the American diet are meat, poultry,
fish, dairy products, and fats and oils. Animal products tend to be higher in
both total and saturated fats than most plant sources. Although some plant
fats such as coconut and palm kernel oils also contain high proportions of
saturated fatty acids, these make minor contributions to total intake of
saturated fats in the United States. Dietary cholesterol is found only in
foods of animal origin, such as eggs, meat, poultry, fish, and dairy prod-
10
Summary and Recommendations tl
ucts. To help reduce consumption of total fat, especially saturated fat and
cholesterol, food choices should emphasize intake of fruits, vegetables,
and whole grain products and cereals. They should also emphasize con-
sumption of fish, poultry prepared without skin, lean meats, and low-fat
dairy products. Among vegetable fats, those that are more unsaturated are
better choices.
0 Energy and weight control: Achieve and maintain a desirable body
weight. To .do so, choose a dietary pattern in which energy (caloric)
intake is consistent with energy expenditure. To reduce energy intake,
limit consumption of foods relatively high in calories, fats, and sugars
and minimize alcohol consumption. Increase energy expenditure
through regular and sustained physical activity.
People are considered overweight if their body mass index, or BMI (a ratio
of weight to height described in the Report), exceeds the 85th percentile for
young American adults (approximately 120 percent of desirable body
weight); they are considered severely overweight if their BMI exceeds the
95th percentile (approximately 140 percent of desirable body weight).
Overweight individuals are at increased risk for diabetes mellitus, high
blood pressure and stroke, coronary heart disease, some types of cancer,
and gallbladder disease. Epidemiologic and animal studies have shown
consistently that overall risk for death is increased with excess weight,
with risk increasing as severity of obesity increases.
Type II (noninsulin-dependent) diabetes mellitus accounts for approxi-
mately 90 percent of all cases of diabetes and is strongly associated with
obesity. Clinical studies indicate that weight loss can improve control of
Type II diabetes.
Obesity increases the risk for high blood pressure, and consequently for
stroke; it also increases blood cholesterol levels associated with coronary
heart disease. In addition, it appears to be an independent risk factor for
coronary heart disease. Weight reduction has been shown to reduce high
blood pressure and high blood cholesterol. Most obese individuals who
achieve a more desirable body weight improve their cholesterol profile,
achieving a decrease in both total blood cholesterol and LDL (low density
lipoprotein) cholesterol.
Some studies have found an association between overweight and increased
risk for several cancers, especially cancer of the uterus and breast. In
addition, overweight increases the risk for gallbladder disease.
11
0 Nutrition and Health
More than a quarter of American adults are overweight. Black women age
45 and above have the highest prevalence, about 60 percent. Although
evidence suggests a genetic component to the tendency of many people to
become overweight, patterns of dietary caloric intake and energy expendi-
ture play a key role. Sustained and long- term efforts to reduce body weight
can best be achieved as a result of improving energy balance by reducing
energy consumption and raising energy expenditure through physical ac-
tivity and exercise.
Maintenance of desirable body weight throughout the lifespan requires a
balance between energy (calorie) intake and expenditure. Weight control
may be facilitated by decreasing energy intake, especially by choosing
foods relatively low in calories, fats, and sugars, and by minimizing alcohol
consumption. Energy expenditure can be enhanced through regular phys-
ical activities such as daily walks or by jogging, bicycling, or swimming at
least three times a week for at least 20 minutes.
0 Compk carbohydrates andfiber Increase consumption of whole grain
foods and cereal products, vegetables (includiug dried beaus and peas),
and fruits.
Dietary patterns emphasizing foods high in complex carbohydrates and
fiber are associated with lower rates of diverticulosis and some types of
cancer. The association shown in epidemiologic and animal studies be-
tween diets high in complex carbohydrates and reduced risk for coronary
heart disease and diabetes mellitus is, however, difficult to interpret. The
fact that such diets tend also to be lower in energy and fats, especially
saturated fat and cholesterol, clearly contributes to this difficulty. Some
evidence from clinical studies also suggests that water-soluble fibers from
foods such as oat bran, beans, or certain fruits are associated with lower
blood glucose and blood lipid levels. Consuming foods with dietary fiber is
usually beneficial in the management of constipation and diverticular
disease.
While inconclusive, some evidence also suggests that an overall increase in
intake of foods high in fiber might decrease the risk for colon cancer.
Among several unresolved issues is the role of the various types of fiber,
which differ in their effects on water-holding capacity, viscosity, bacterial
fermentation, and intestinal transit time.
Other food components associated with decreased cancer risk are com-
monly found in diets high in whole grain cereal products containing com-
plex carbohydrates and fiber. In addition, some epidemiologic evidence
Summary and Recommendations 0
suggests that frequent consumption of vegetables and fruits, particularly
dark green and deep yellow vegetables and cruciferous vegetables (such as
cabbage and broccoli), may lower risk for cancers of the lung and bladder
as well as some cancers of the alimentary tract. However, the specific
components in these foods that may have protective effects have not yet
been established. Current evidence suggests the prudence of increasing
consumption of whole grain foods and cereals, vegetables (including dried
beans and peas), and fruits.
o Sodium: Reduce intake of sodium by choosing foods relatively low in
sodium and limiting tbe amount of salt added in food preparation and at
the table.
Studies indicate a relationship between a high sodium intake and the
occurrence of high blood pressure and stroke. Salt contains about 40
percent sodium by weight and is used widely in the preservation, process-
ing, and preparation of foods. Although sodium is necessary for normal
metabolic function, it is consumed in the United States at levels far beyond
the 1.1 to 3.3 grams per day found to be as safe and adequate for adults by
the National Research Council. Average current sodium intake for adults
in the United States is in the range of 4 to 6 grams per day.
Blacks and persons with a family history of high blood pressure are at
greater risk for this condition. While some people maintain normal blood
pressure levels over a wide range of sodium intake, others appear to be
"salt sensitive" and display increased blood pressure in response to high
sodium intakes.
Although not all individuals are equally susceptible to the effects of so-
dium, several observations suggest that it would be prudent for most
Americans to reduce sodium intake. These include the lack of a practical
biological marker for individual sodium sensitivity, the benefit to persons
whose blood pressures do rise with sodium intake, and the lack of harm
from moderate sodium restriction.
Processed foods provide about a third or more of dietary sodium. Because
about another third of the sodium consumed by Americans is added by the
consumer, much can be done to reduce sodium consumption by using less
salt at the table and substituting alternative flavoring such as herbs, spices,
and lemon juice in the preparation of foods. In addition, choices can be
made of foods modiied to lower sodium content and less frequent choices
could be made of foods to which sodium is added in processing and
preservation.
13
O Nutrition and Health
o Alcohol: To reduce the risk for chronic disease, take alcohol only in
moderation (no more than two drinks a day), ifat all. Avoid drinking any
alcohol before or while driving, operating machinery, taking medica-
tions, or engaging in any other activity requiring judgment. Avoid
tkhking alcohol while pregnant.
Alcohol is a drug that can produce addiction in susceptible individuals,
birth defects in some children born to mothers who drink alcohol during
pregnancy, impaired judgment, impaired ability to drive automobiles or
operate machinery, and adverse reactions in people taking certain medica-
tions. In addition, alcohol abuse has been associated with disrupted family
functioning, suicides, and homicides.
Excessive use of alcohol is also associated with liver disease, some types of
cancer, high blood pressure, stroke, and disorders of the heart muscle.
Extensive epidemiologic and clinical evidence has identified alcohol con-
sumption as the principal cause of liver cirrhosis in the United States, at
least in part as a result of the direct toxic effects of alcohol on the liver.
Smoking and alcohol appear to act synergistically to increase the risk for
cancers of the mouth, larynx, and esophagus. Less conclusive and some-
what conflicting evidence suggests a role of alcohol in other types of
cancers such as those of the liver, rectum, breast, and pancreas.
Studies indicate a direct association between increased blood pressure and
the consumption of alcohol at levels beyond about two drinks" daily.
Extremely excessive alcohol consumption is associated with cardiomyop-
athy. Alcohol consumption by the mother during pregnancy has also been
associated with fetal malformations.
Although consumption of up to two drinks per day has not been associated
with disease among healthy men and nonpregnant women, surveys suggest
that at least 9 percent of the total population consumes two or more drinks
per day and those in this group need to reduce their alcohol consumption. A
threshold level of safety for alcohol intake during pregnancy has not been
established. Thus, pregnant women and women who may become preg-
nant should avoid drinking alcohol.
lone drink is defined as a 12 ounce beer, a 5 ounce glass of wine, or 1% fluid ounces (one
jigger) of distilled spirits, each of which contains about 1 ounce of alcohol.
14
Summary and Recommendations O
Other Issues for Some People
0 Fluoride: Community water systems should contain fluoride at optimal
levels for prevention of tooth decay. If such water is not available, use
other appropriate sources of fluoride.
The most efficient means of making fluoride available to the general public
to reduce dental disease is through drinking water. Numerous epidemio-
logic and clinical studies have attested to the efficacy, safety and cost-
effectiveness of systemic fluoride in the prevention of tooth decay. Life-
time use of water containing an optimal fluoride concentration of approxi-
mately 1 part per million has been shown to reduce the prevalence of dental
caries by more than 50 percent. Water fluoridation is considered one of the
most successful public health efforts introduced in the United States.
For children living in areas with inadequate concentrations of fluoride in
the water, supplementary fluoride sources should be used at dosages that
depend on the fluoride content of the local water supply and the age of the
child. The effectiveness of prenatal fluoride administration, however, is
uncertain because clinical studies of its effects on subsequent caries inci-
dence have been equivocal. Excessive fluoride should be avoided because
it may cause mottling of developing teeth.
0 Sugurs: Those who are particularly vulnerable to dental caries (cavities),
especially children, should limit their consumption and frequency of use
of foods high in sugars.
Although genetic, behavioral, and other dietary factors also influence
dental health, the major role of sugars in promotion of tooth decay is well
established from animal, epidemiologic, clinical, and biochemical studies.
Newly erupting teeth are generally more vulnerable to decay than mature
teeth.
Research has shown that three conditions must exist for the formation of
dental caries: the presence of fermentable carbohydrate, acid-producing
bacteria, and a susceptible tooth. Caries-producing bacteria metabolize a
range of sugars (glucose, fructose, maltose, lactose, and sucrose) to acids
that demineralize teeth. The unique role of sucrose (common table sugar)
in dental caries is related to its special ability to be converted by these
bacteria into long, complex molecules that adhere firmly to teeth and form
plaque.
0 Nutrition and Health
The most important diet-related interventions are fluoridation of drinking
water, or the use of other means of fluoride administration, and control of
intake of sugars. While fluoride is the most important factor overall in
dental caries prevention, reduction in the frequency of consumption and in
the quantity of sugar-rich foods in the diet will also help reduce decay.
Sticky sweet foods that adhere to the teeth are more cariogenic than those
that wash off quickly. The longer cariogenic foods remain in the mouth, the
more they are likely to increase the initiation and progression of tooth
decay.
0 Calcium: Adolescent girls and adult women should increase consumption
of foods high in calcium, including low-fat dairy products.
Inadequate dietary calcium consumption in the first three to four decades
of life may be associated with increased risk for osteoporosis in later life.
Osteoporosis, a chronic disease characterized by progressive loss of bone
mass with aging, occurs in both women and men, although postmenopausal
women are twice as likely as men to have severe osteoporosis with conse-
quent bone fractures. Evidence shows that chronically low calcium intake,
especially during adolescence and early adulthood, may compromise de-
velopment of peak bone mass. In postmenopausal women, the group at
highest risk for osteoporosis, estrogen replacement therapy under medical
supervision is the most effective means to reduce the rate of bone loss and
risk for fractures. Maintenance of adequate levels of physical activity and
cessation of cigarette smoking have also been associated with reduced
osteoporosis risk.
Although the precise relationship of dietary calcium to osteoporosis has
not been elucidated, it appears that higher intakes of dietary calcium could
increase peak bone mass during adolescence and delay the onset of bone
fractures later in life. Thus, increased consumption of foods rich in calcium
may be especially beneficial for adolescents and young women. Food
sources of calcium consistent with other dietary recommendations in this
Report include low-fat dairy products, some canned fish, certain vegeta-
bles, and some calcium-enriched grain products.
o Iron: Children, adolescents, and women of childbearing age should be
sure to consume foods that are good sources of iron, such as lean meats,
fish, certain beans, and iron-enriched cereals and whole grain products.
This issue is of special concern for low-income families.
Dietary iron deficiency is responsible for the most prevalent form of
anemia in the United States. Iron deficiency hampers the body's ability to
produce hemoglobin, a substance needed to carry oxygen in the blood. A
16
Summary and Recommendations O
principal consequence of iron deficiency is reduced work capacity, al-
though depressed immune function, changes in behavior, and impaired
intellectual performance may also result. Because of the serious conse-
quences of iron deficiency, continual monitoring of the iron status of
individuals at high risk-particularly children from low-income families,
adolescents, and women of childbearing age-is vital, as is treatment of
those identified to be iron deficient.
Proper infant feeding-preferably breastfeeding, otherwise use of iron-
fortified formula-is the most important safeguard against iron deficiency
in infants. Among adolescents and adults, iron intake can be improved by
increasing consumption of iron-rich foods such as lean meats, fish, certain
kinds of beans, and iron-enriched cereals and whole grain products. Also,
consuming foods that contain vitamin C increases the likelihood that iron
will be absorbed efficiently.
Policy Implications
Dietary Guidance
General Public
Educating the public about the dietary choices most conducive to preven-
tion and control of certain chronic diseases is essential. Educational efforts
should begin in primary school and continue throughout the secondary
grades, and should focus on the dietary principles outlined in this Report-
the potential health benefits of eating a diet that is lower in fat (especially
saturated fat) and rich in complex carbohydrates and fiber. The importance
of adequate physical activity should also be stressed. Efforts should con-
tinue throughout each stage of life to promote the principles outlined in the
Dietary Guidelines for Americans.
Special Populations
A disproportionate burden of diet-related disease is borne by subgroups in
our population. Black Americans, for example, have higher rates of high
blood pressure, strokes, diabetes, and other diseases associated with
obesity (but lower rates of osteoporosis) than the general population. Some
groups of Native Americans exhibit the highest rates of diabetes in the
world. Pregnant and lactating women also have special nutritional needs.
Particular effort should be made to identify and remove the barriers to
optimal health and nutritional status in such high-risk groups, using meth-
ods that take into consideration their diverse cultural backgrounds.
17
O Nutrition and Health
Many older persons suffer from chronic diseases that can reduce functional
independence; many take multiple medications that may adversely interact
with nutrients. Sound public education directed toward this group-and
professional education directed toward individuals who care for older
Americans-should focus on dietary means to reduce risk factors for
chronic disease, to promote functional independence, and to prevent ad-
verse consequences of use of medications.
Health Professionals
Improved nutrition training of physicians and other health professionals is
needed. Training should emphasize basic principles of nutrition, the role of
diet in health promotion and disease prevention, nutrition assessment
methodologies and their interpretation, therapeutic aspects of dietary in-
tervention, behavioral aspects of dietary counseling, and the role of dieti-
tians and nutritionists in dietary counseling of patients.
Programs and Services
Food Labels
Food labeling offers opportunities to inform people about the nutrient
content of foods so as to facilitate dietary choices most conducive to
health. Food manufacturers should be encouraged to make full use of
nutrition labels. Labels of processed foods should state the content of
calories, protein, carbohydrate, fats, cholesterol, sodium, and vitamins
and minerals. To the extent permitted by analytical methods, manufactur-
ers should disclose information where appropriate on the content of satu-
rated and unsaturated fatty acids and total fiber in foods that normally
contain them. Descriptive terms such as "low calorie" and "sodium re-
duced" in compliance with the Food and Drug Administration's regula-
tions for food labeling may also be helpful, and the expanded use of these
terms should be encouraged.
Nutrition Services
Health care programs for individuals of all ages should include nutrition
services such as, when appropriate, nutrition counseling for individuals or
groups, interpretation and implementation of prescribed therapeutic diets
tailored to individual food preferences and lifestyle, referral to appropriate
community services and food assistance programs, monitoring of prog-
ress, and appropriate followup. These services should routinely incorpo-
rate assessment of nutritional status and needs based on established crite-
18
Summary and Recommendations O
ria to identify individuals with nutritional risk factors who would profit
from preventive measures and those with nutritional disorders who need
remedial care.
Food Services
Lack of access to an appropriate diet should not be a health problem for any
American. Wherever food is served to people or provided through food
assistance programs, it should reflect the principles of good nutrition stated
in this Report. Whether served in hospitals, schools, military installations,
soup kitchens, day care centers, or nursing homes, or whether delivered to
homes, food service programs offer important opportunities for improving
health and providing dietary education. Such programs should pay special
attention to the nutritional needs of older people, pregnant women, and
children, especially those of low income or other special dietary needs.
Because a large proportion of the population takes meals in restaurants and
convenience food facilities, improvements in the overall nutritional bal-
ance of the meals served in such places can be expected to contribute to
health benefits.
Food service programs should also take particular care to ensure that
special diets lower in fat, especially saturated fat, are provided to people
with elevated blood cholesterol, heart disease, or diabetes; that diets low in
sodium are provided to individuals with high blood pressure; and that
protein-restricted diets are made available to people with end-stage kidney
disease.
Food Products
The public would benefit from increased availability of foods and food
products low in calories, total fat, saturated fat, cholesterol, sodium, and
sugars, but high in a variety of natural forms of fiber and, perhaps, certain
minerals and vitamins. Food manufacturers can contribute to improving
the quality of the American diet by increasing the availability of palatable,
easily prepared food products that will help people to follow the dietary
principles outlined here. Because the public is becoming increasingly
conscious of the role of nutrition in health, development of such products
should also benefit the food industry.
Research and Surveillance
Impressive evidence already links nutrition to chronic disease. However,
much more information is needed to continue to identify changes in the
19
O Nutrition and Health
national diet that will lead to better health for the Nation. Gaps in our
knowledge of nutrition suggest future research and surveillance needs.
Examples are:
o The role of specific dietary factors in the etiology and prevention of
chronic diseases.
o The childhood dietary pattern that will best prevent later development
of chronic diseases.
o The effects of maternal nutrition on the health of the developing fetus.
o The nutrient and energy requirements of older adults.
o How nutrient requirements translate into healthful dietary patterns.
o The development of biodhemical markers of dietary intake to monitor
better the effects of dietary intervention.
o The identification of effective educational methods to translate dietary
recommendations into appropriate food choices.
o The establishment of a nutrition surveillance system that will enhance
the monitoring of population-specific and State-specific trends in the
occurrence of nutrition-related risk factors and conditions.
20
Chapter 1
Introduction and Background
Power of nutriment reaches to bone and to
all the parts of bone, to sinew, to vein, to
artery, to muscle, to membrane, to flesh,
fat, blood, phlegm, marrow, brain, spinal
marrow, the intestines, and all their parts: it
reaches also to heat, breath, and moisture.
Hippocrates (-377 B.C.)
Introduction
It has long been understood that optimal health depends on adequate
nutrition, yet knowledge of the ways in which specific dietary factors affect
the risk for disease is incomplete. Dietary deficiencies can be manifested in
various ways. A deficient intake of energy or nutrients can lead to protein-
energy malnutrition or to classic deficiency diseases such as rickets, pel-
lagra, or iron deficiency anemia. Protein-energy malnutrition and diseases
due to deficiencies of various nutrients are prominent causes of premature
death and disability in developing countries but, with a few exceptions,
appear to have been eliminated in the United States.
When nutrient deficiencies are reported in this country, they are most often
observed to be associated with poverty, the additional nutrient require-
ments of pregnancy or infancy (IOM 1985), the abuse or neglect of children
or older persons, or some combination of these factors. They also are
observed to result from the restricted food intake that sometimes accom-
panies aging, alcohol or drug abuse, unusually severe and prolonged injury
or illness (including prolonged hospitalization), excessive dieting, or re-
strictive dietary practices. Thus, pregnant women, young infants, chil-
dren, older persons, alcohol and drug abusers, and chronically ill and
disabled individuals are at greatest risk for malnutrition due to dietary
deficiencies, especially if their income is low. Whatever its root cause,
inadequate nutrition retards normal growth, lowers resistance to infectious
disease, impairs maternal and child health, and may adversely affect the
ability to function at peak physical and mental capacity. These issues are
discussed in detail in the relevant chapters of this Report.
21
O Nutrition and Health
As problems of nutritional deficiency have diminished in the United States,
they have been replaced by problems of dietary imbalance and excess.
These imbalances and excesses have contributed to the increased preva-
lence and severity of chronic diseases that are major causes of death and
disability among Americans. Table l-1 lists the 10 leading causes of death
in this country. Among them, five-coronary heart disease and generalized
atherosclerosis, stroke, some types of cancer, and diabetes-have been
associated with dietary excesses or imbalances, and another three-cir-
rhosis of the liver, accidents, and suicides-are often the result of exces-
sive alcohol intake. Together, these conditions account for as much as 70
percent of annual deaths among Americans (Collins 1986; NCHS 1986).
Dietary excesses or imbalances also have been associated with high blood
pressure, obesity, dental diseases, osteoporosis, and, perhaps, kidney and
gastrointestinal diseases. Such conditions also contribute to much illness,
disability, and death in the United States, and thus to substantial human
and economic costs to society.
Table l-l
Estimated Total Deaths and Percent of Total Deaths for the
10 Leading Causes of Death: United States, 1987
Rank Cause of Death
Number
Percent
of Total
Deaths
la
2a
3a
4b
5
6
7a
8b
9b
IO=
Heart diseases 759,400
(Coronary heart disease) (511,700)
(Other heart disease) (247,700)
Cancers 476,700
Strokes 148,700
Unintentional injuries 92,500
(Motor vehicle) W5,800)
(All others) (45,700)
Chronic obstructive hmg diseases 78,ooO
Pneumonia and influenza w600
Diabetes mellitus 37,800
Suicide 29,600
Chronic liver disease and cirrhosis 26,000
Atherosclerosis 23,100
35.7
(24.1)
(11.6)
22.4
7.0
(i::,
(2.2)
3.7
3.2
1.8
1.4
1.2
1.1
. . . All causes 2,125,loo
BCauses of death in which diet plays a part.
Wauses of death in which excessive alcohol consumption plays a part.
100.0
Source: National Center for Health Statistics 1988.
22
Introduction and Background cl
Much about the ways in which excessive intake of energy and nutrients
might affect health remain to be elucidated. Yet despite uncertainties,
much has been learned about diet-disease relationships. This first Surgeon
General's Report on Nutrition and Health examines the current state of
knowledge of associations among dietary patterns, nutrients, and certain
disease conditions. Its purpose is to review the available research evidence
that relates diet to health to establish a basis for policies that promote
dietary means to improve health.
Development and Organization of the Report
This Surgeon General's Report on Nutrition and Health has been devel-
oped in response to the increasing interest of the public, health profession-
als, and policy leaders in the role of diet in health promotion and prevention
of chronic disease. In preparing the Report, the Public Health Service
(PHS) reviewed past and current research related to diet and disease as a
basis for examination of the implications for public policies on nutrition
education, services, and research.
The Report reviews current knowledge of the influence of dietary factors
on specific aspects of health. This first chapter introduces the major
themes of the Report in their historical context; it also reviews and synthe-
sizes basic information about essential nutrients in the human diet, the
levels of intake required for human health, and American dietary patterns,
and it explains the criteria used to examine the various kinds of research
studies that are reviewed throughout the Report. Chapters 2 through 14
describe the scientific research that has examined associations between
specific dietary factors and selected disease conditions in the United States
(Coronary Heart Disease, High Blood Pressure, Cancer, Diabetes,
Obesity, Skeletal Diseases, Dental Diseases, Kidney Diseases, Gastroin-
testinal Diseases, Infections and Immunity, Anemia, Neurologic Disor-
ders, and Behavior). Chapters 15 (Maternal and Child Nutrition) and 16
(Aging) review the special nutritional challenges at especially vulnerable
stages of the human life cycle. The interactions between nutrients and
alcohol and between nutrients and drugs, and the effects of these sub-
stances on human nutritional status, are reviewed in chapters 17 and 18,
respectively. The Report closes with a final chapter on dietary fads and
frauds.
Most of the chapters follow a common format. Each begins with a brief
introduction and a section entitled Historical Perspective that is designed
to establish a historical context for the area under review. A section on
23
O Nutrition and Health
Significancefor Public Health contains information currently available on
the incidence, prevalence, and cost to the Nation of each of the conditions
under review. Many of the chapters contain a further introductory Scien-
tific Background section that summarizes technical information needed to
understand the research issues reviewed in the Report.
The major part of the chapters is devoted to a review of Key Scientific
Issues that summarizes current knowledge about possible associations
between dietary factors and disease that are most relevant to public policy.
Each chapter closes with a section entitled Implications for Public Health
Policy that summarizes the signiftcance of the research evidence for di-
etary guidance and education, nutrition programs and services, and nutri-
tion research and surveillance. Finally, Literature Cited provides an exten-
sive list of references to support the scientific findings in each chapter.
Historical Perspective
Throughout history, human societies have observed relationships between
the consumption of certain foods and the preservation of good health or the
prevention or treatment of diseases. Although the word "diet" occurs
frequently in writings attributed to Hippocrates and to Galen, the term
"nutrition" did not appear as an English word until the mid-1400's and was
used infrequently until the second half of the 19th century (Todhunter
1973). The modem concept of nutrition-that human life depends on a
steady intake of a variety of specific dietary substances in defined
amounts-is less than 200 years old.
Development of Nutritional Science
Conditions related to nutritional deficiency, such as beriberi, rickets, or
scurvy, were described in very early writings, but the identification of the
specific dietary factors required to prevent or treat these conditions began
to occur only in the late 18th century and did not approach completion for
another 150 years. Some of the major events in this gradual development of
nutrition as a science from the earliest records to 1950 are listed in Table
l-2. The chapters of this Report review the great expansion of nutrition
research and knowledge that has occurred since then.
The earliest efforts to establish the scientific basis of nutrition are usually
attributed to the French chemist Lavoisier, who demonstrated in 1789 that
the oxygen breathed in air was consumed in the body to produce carbon
dioxide and water, and that this central metabolic process was measurable,
variable, and related to both the level of physical activity and the amount of
24
Introduction and Background 0
Table 1-2
Selected Events in the History of Nutritional Science to 1950
c. 1500 B.C.
c. 400 B.C.
c. 300 B.C.
c. 200 A.D.
1250
1614
1650
1730
1747
1752
1780
1789
17%
1807
1810-23
1810
1816
1827
1833
1838
1839
1840
Papyrus Ebers contains prescription believed to refer to diabetes.
Hippocrates wrote of relationship of diet to health.
Beriberi described in ancient Chinese texts.
Arataeus gave the name diabetes to the condition of "too much
passing of urine."
Joinville described scurvy among troops of Louis IX at the siege
of Cairo.
Sanctorius published studies relating body weight to food intake.
Glisson described rickets in De Rachitide.
Casal described pellagra, calling it "ma1 de la rosa."
Lind proved that citrus fruits cure scurvy in first controlled
human dietary experiment. Menghini established presence of iron
in blood.
Reaumur published experiments on digestion in birds.
Spallanzani produced evidence that digestion was the chemical
action of gastric juices.
Lavoisier and Seguin make first measurements relating oxygen
consumption to human energy metabolism. Cod liver oil used as
treatment for rickets.
Lemon juice offtcially introduced in British Navy to prevent
SCUNY.
Davy isolated sodium, potassium, calcium, magnesium, sulphur,
and boron.
Chevreul studied chemistry of animal fats.
WolIaston isolated cystic oxide (later named cystine) from
urine--first amino acid discovered.
Magendie identified dietary nitrogen requirements in dogs.
Prout classified food constituents as saccharine, oily, and
albuminous (sugar, fat, and protein).
Beaumont reported observations and experiments on digestion in
his patient St. Martin.
Mulder introduced the term "protein."
Boussingault conducts first nitrogen balance studies in animals.
Liebig published Animal Chemistry, stating basic principles of
metabolism.
25
O Nutrition and Health
Table l-2 (continued)
1843
1848
1849-57
1850
1850-52
186641
1867
1877
1885
18%
1897
1902
1909-28
1912
1914
1916
1918
1919-22
1921-24
1922
1928
1929
1931-37
1932
1933
Chossat studied the effect of starvation on the body using
pigeons.
Addison described pernicious anemia.
Bernard elucidated digestive action of pancreatic juices and
glycogenic function of liver.
Livingstone described xerophthalmia (due to vitamin A
deficiency) in Africa.
Chatin in France used iodine to prevent goiter.
Voit and Pettenkofer explained protein metabolism.
Boussingault recognized iron as essential nutrient.
Pavlov began classic studies on digestion in dogs.
Takaki demonstrated in controlled dietary experiments with
Japanese Navy sailors that beriberi could be prevented.
Atwater and Bryant introduced their basic reference, Chemical
Composition of American Food Materials.
Eijkman published his work on causes of beriberi.
Rubner showed that food components increased metabolism by
different amounts.
Osborne and Mendel studied the nutritive value of protein.
Funk coined the term "vitamine."
Goldberger established dietary cause of pellagra.
McCollum and Davis and Osborne and Mendel discovered
accessory dietary factors "fat-soluble A" and "water-soluble B."
Mellanby showed that experimental rickets in dogs is due to lack
of fat-soluble vitamin.
Water-soluble B factor shown to be more than one factor.
Blindness in children shown to be result of lack of vitamin A.
McCollum identified vitamin D in cod liver oil.
Goldberger identified pellagra-preventing factor in yeast.
Role of intrinsic and extrinsic factors in pernicious anemia
discovered.
Fluoride content of drinking water identified as cause of mottled
enamel of teeth and prevention of tooth decay.
Vitamin C isolated from lemon juice. Warburg and Christian
identified riboflavin and defined its molecular function.
Williams identified kwashiorkor as a nutritional disease.
26
Introduction and Background O
Table l-2 (continued)
1938
1941
Rose classified amino acids as essential and nonessential.
Evidence provided for the influence of prenatal diet on the health
of the newborn infant.
! 944-46
Keys and coworkers studied effects on young men of
experimentally induced semistarvation and methods of dietary
rehabilitation.
I945
1948-49
Grand Rapids. Michigan. becomes the first city in the world to
fluoridate its drinking water to prevent tooth decay.
Crystalline vitamin B,, isolated from liver extract and shown to
contain cobalt.
1949 Framingham Study of coronary heart disease risk factors begins.
Sources: Darby 1985; McCollum 1957; Murlin 1948; Olson 1978; Todhunter 1962, 1973,
1976.
food ingested (Lusk 1933). In the 19th century, European and American
scientists isolated and began to identify the major groups of nutrients in the
diet, to develop the first estimates of nutrient requirements, and to explore
the basics of energy metabolism. For example, in 1816, Magendie of
France established that nitrogen-containing compounds were essential in
the diet of dogs; in 1838, these compounds were given the name protein
(from the French word for "primary substance"). In 1814, the French
chemist Chevreul discovered that fats consisted of fatty acids attached to a
glycerol molecule. By 1834, the London physician Prout was able to
introduce the idea that food consists of substances called saccharine, oily,
and albuminous-today called carbohydrates, fats, and proteins
(Todhunter 1959). Later in the century, Rubner ofGermany and Atwater of
the United States established the energy values of these substances as
approximately 4, 9, and 4 kcal/g, respectively (McCollum 1957).
Thus, from the time of Lavoisier to the end of the 19th century, knowledge
of nutritional science grew to encompass the metabolic basis of energy
production from food, the classification of nutrients and sources of energy,
the dependence of energy requirements on physical activity, the influence
of diet on body weight and of fevers on metabolism of food substances, the
principles of metabolic homeostasis, and the roles of specific essential
nutrients in human physiology (Murlin 1948). During this period, lemon
juice was found to prevent scurvy, iodine to prevent goiter, and in-
completely milled rice to prevent beriberi. Despite these advances, the
most fundamental concepts about nutrition were still poorly developed at
the beginning of the 20th century. It was not until the first half of this
27
O Nutrition and Health
century that scientists identified human nutritional requirements, charac-
terized the nutritional value of proteins, and identified the amino acids,
vitamins, fatty acids, and minerals essential in the human diet (Todhunter
1976). For example, Osborne and Mendel of Yale University elucidated the
differences between complete and incomplete proteins during the first
decades of this century. Later, Rose of the University of Illinois estab-
lished which of the amino acids were essential and estimated how much of
each was required each day.
The diseases of scurvy, beriberi, rickets, and pellagra had been described
in very early writings, but their specific causes were not identified until
after 1900. In 1906, Hopkins of Cambridge University suggested that food
contained certain accessory factors necessary for prevention of these
conditions. In 1912, Funk named these factors "vitamines," later called
vitamins as more was learned about their chemical structure (Rosen 1958).
Early in the century, the dietary cause of pellagra was established by
Goldberger, a PHS physician, and fat- and water-soluble vitamins were
isolated and characterized (McCollum 1957). Also during this period,
kwashiorkor was identified as a nutritional disease and the importance of
prenatal diet on the health of newborn infants began to be appreciated
(Darby 1985). Over the next three decades, all of the vitamins were
identified, starting with the isolation of a fat-soluble substance in egg yolk
by McCollum at the University of Wisconsin, now known as vitamin A,
and continuing with the discoveries of folic acid, vitamin Br2, and other B
vitamins in the 1930's and 1940's (McCollum 1957). The essential nature of
trace elements such as selenium and zinc were finally recognized in the
1950's and 1960's (Darby 1985).
After World War II, the major focus of attention in nutrition began to shift
away from acute nutrient deficiency diseases. The advent of improved
transportation systems and home refrigeration and frozen foods expanded
the year-round availability of fresh and wholesome foods, and food for-
tification helped to increase the availability of previously scarce nutrients.
At the same time, vaccines, antibiotics, and other advances in medicine
and health prevented and controlled many of the infectious diseases that
had previously shortened the human lifespan. Thus, chronic degenerative
diseases became more important as causes of illness and death. Nutrition
scientists began to examine the relationship of modem dietary patterns and
practices to these chronic diseases-cardiovascular disease, cancer, and
diabetes, for example-that were becoming increasingly prevalent among
28
Introduction and Background cl
Americans in middle and late life, and attention shifted to the effects of
specific nutrients and dietary factors on the long. slow development of
these conditions.
Evolution of .Federal Nutrition Policy
As knowledge developed in the nutrition sciences and on the health effects
of food, and as food availability and consumption patterns became more
apparent, nutrition assumed an increasingly visible role in pubtic policy.
By 1979, the Federal Government was involved in efforts to ensure an
adequate, safe, and nutritious food supply for Americans through spon-
sorship of more than 350 programs in key areas of nutrition policy: agricul-
tural support, food safety and regulation, food fortification, food assis-
tance, nutrition services and training, food intake and nutritional status
monitoring, food and nutrition research, and food and nutrition education
(Comptroller General 1979). Some of these programs had rdots that
reached back to the turn of the century. but since World War I1 the
Government's efforts have increasingly focused on meeting the needs of
high-risk groups and on the role of-diet in health promotion and disease
prevention. Table l-3 presents a chronological listing of selected events in
the development of Federal domestic nutrition policies; the history of
Federal initiatives in the major areas of nutrition policy is reviewed below.
Table 1-3
Selected Federal Domestic Nutdtion Policy Initiatives, 1862-1988
1862
1867
1887
1889
U.S. Department of Agriculture (USDA) created. Morrill Act
establishes land grant colleges.
O&e of Education established-wi;h responsibilities for
nutrition education within public schools.
Hatch Act establishes agricultural experiment stations.
Federal research laboratory established at Staten Island.
Name is changed to the National Institute of Health in 1930.
U.S. Public Health Service Commissioned Corps authorized
for duty on communicable, nutritional, and other diseases.
1893
1906
1914
1916
USDA authorized by Congress to conduct research on
agriculture and human nutrition.
The Pure Food and Drug (Wiley) Act prohibits interstate
commerce and misbranded and adulterated foods, drinks, and
drugs. Federal Meat Inspection Act passed.
Cooperative Extension Service created as part of USDA.
USDA publishes Food for Young Children, first dietary
guidance pamphlet.
29
u Nutrition and Health
Table l-3 (continued)
1917
1921-29
1924
1927
1930
1933
1935
1936-37
1938
1939
1940
1941
1946
1947
1954
U.S. Food Administration established to supervise World Wa,
I food supply. First dietary recommendations issued by
USDA-Five Food Groups.
Maternity and Infancy Act enabled State health departments
to employ nutritionists.
Addition of iodine to salt to prevent goiter is first U.S. food
fortification program.
Food, Drug, and Insecticide Administration established. Name
is changed to Food and Drug Administration (FDA) in 1932.
USDA and Federal Emergency Relief Administration buy and
distribute surplus agricultural commodities as food relief.
Public Health Service Hygienic Laboratory designated as
National Institute of Health (later changes to National
Institutes of Health).
Agricultural Act amendments permit purchase of surplus
commodities for donation to child nutrition and school lunch
programs.
Food Distribution Program established. Social Security Act
authorizes grants to States for nutrition services to mothers
and children .
USDA conducts first Nationwide Food Consumption Survey
(NFCS).
The Food, Drug and Cosmetic (FD&C) Act includes
provisions for food standards. FDA nutrition research
program established. Social Security Act provides support for
role of nutrition in health.
Federal Surplus Commodities Corporation initiates
experimental Food Stamp Program.
National Defense Advisory Commission draws attention to
malnutrition in the United States.
President Roosevelt calls National Nutrition Conference, with
announcement of the first Recommended Dietary Allowances
by the Food and Nutrition Board. FDA promulgates standards
for enrichment of flour and bread with B-complex vitamins
and iron.
National School Lunch Program established.
Laboratories of Nutrition, Chemistry, and Pathology of the
National Institutes of Health incorporated into Experimental
Biology and Medicine Institute.
Special Milk Program established.
30
Introduction and Background 0
Table 1-3 (continued)
1955
1956
1958
1961
1%3 and 1965
1%5
1966
1966-70
1968
1968-70
I%9
1971-74
Interdepartmental Committee on Nutrition for National
Defense established (discontinued 1%7).
Title VII of the Public Health Service Act authorizes funds to
support graduate training in public health nutrition.
Food Additives Amendment to FD&C Act prohibits use of a
food additive until safety established by manufacturer.
Delaney Clause prohibits carcinogenic additives. GRAS
(Generally Recognized As Safe) list established.
President Kennedy expands the use of surplus food for needy
people at home and abroad and announces a new pilot Food
stamp Program.
Maternal and Child Health and Mental Retardation Planning
Amendments to the Social Security Act allow for an expanded
number of nutritionists in health care programs.
Food Stamp Act passed by Congress. Nationwide Food
Consumption Survey collects first data on dietary intake of
individuals.
Child Nutrition Act passed. School Breakfast Program
established. President Johnson outlines Food for Freedom
Program, the "war on hunger." Allied Health Professions
Personnel Training Act includes support for training of
dietitians.
The Department of Health, Education, and Welfare (DHEW),
which later becomes the Department of Health and Human
Services (DHHS), sponsors a National Academy of Sciences
study, Maternal Nutrition and the Course of Pregnancy, which
makes major recommendations related to the role of nutrition
in human reproduction.
U.S. Senate Select Committee on Nutrition and Human Needs
established.
DHEW sponsors Preschool and Ten-State Nutrition Surveys
that report evidence of hunger and malnutrition in poverty
groups in the United States.
President Nixon calls White House Conference on Food,
Nutrition, and Health. Secretary of Agriculture establishes the
Food and Nutrition Service to administer Federal food
assistance programs.
The National Center for Health Statistics conducts the first
National Health and Nutrition Examination Survey
(NHANES) to measure the nutritional status of the U.S.
population. This is followed by NHANES II in 1976-80,
Hispanic HANES in 1982-84, and NHANES III in 1988.
31
0 Nutrition and Health
1974
1975
1977
1978
1979
1980
1981
1984
1985
Table l-3 (continued)
1972
USDA establishes Special Supplementary Food Program for
Women, Infants, and Children (WIC). Agriculture and
Consumer Protection Act provides price supports to farmers.
Amendments to the Older Americans Act of 1%5 establish a
congregate and home-delivered meals program for older
Americans.
U.S. Senate Select Committee on Nutrition and Human Needs
issues Guidelines for a National Nutrition Policy, prepared by
the National Nutrition Consortium. Safe Drinking Water Act
passed.
National Institutes of Health establishes Nutrition
Coordinating Committee.
U.S. Senate Select Committee on Nutrition and Human Needs
issues two editions of Dietary Goals for the United States.
Food and Agricultural Act and Child Nutrition and National
School Lunch Amendments passed.
Joint Subcommittee on Human Nutrition Research established
in Office of Science and Technology Policy (in 1983 becomes
Interagency Committee on Human Nutrition Research under
joint direction of USDA and DHHS). DHEW and USDA
submit proposal to Congress for National Nutrition Monitoring
System.
DHEW establishes Department-wide Nutrition Policy Board
and issues Healthy People: The Surgeon General's Report on
Health Promotion and Disease Prevention.
USDA and DHHS jointly issue Nutrition and Your Health:
Dietary Guidelines fcr Americans. A second edition follows in
1985. DHHS issues Promoting Health/Preventing Disease:
Objectives for the Nation, which contains 17 nutrition
objectives to be achieved by the year 1990. The Surgeon
General's Workshop on Maternal and Infant Health makes
recommendations about improving nutrition for these
vulnerable groups.
DHHS and USDA issue Joint Implementation PIan for a
Comprehensive National Nutrition Monitoring System,
revised in 1987 as the Operational Plan for the National
Nutrition Monitoring System. The Select Panel for the
Promotion of Child Health, created by Public Law 95-626,
submits to Congress and the Secretary of DHHS its report,
which includes recommendations on nutrition.
The Surgeon General's Workshop on Breastfeeding and
Human Lactation develops strategies for promoting
breastfeeding.
USDA initiates Continuing Survey of Food Intakes by
Individuals. repeated in 1986.
32
Introduction and Background O
Table l-3 (continued)
1986
DHHS and USDA issue Nutrition Monitoring in the United
States, the report of the Joint Nutrition Monitoring Evaluation
Committee.
1988
DHHS publishes The Surgeon General's Report on Nutrition
and Health.
Agricultural Support. The earliest Federal nutrition policies in this area
were designed to strengthen the agricultural production system and to
ensure a consistent and adequate food supply. In 1862. the U.S. Depart-
ment of Agriculture (USDA) was created, and the Morrill Act established
land grant universities as sites for agricultural training and research. The
Hatch Act of 1887 authorized the creation of agricultural experiment
stations. As a result of these and other policies. food production increased
and farmers began to produce more food than could be consumed. Even-
tually, a system of commodity price and income supports was developed to
stabilize the economic condition of the farm sector. The Agricultural and
Consumer Protection Act of 1973 and the Food and Agriculture Act of 1977
established the basis for current agricultural support policies (Stucker and
Boehm 1978; Boehm 1979).
Food Safety and Regulation. The pure food movement of the late 1800's,
led by Dr. Harvey Wiley, chief of the Government's Bureau of Chemistry,
and popularized by the publication of Upton Sinclair's novel of 1906, The
Jungle, led Congress to pass the Pure Food and Drug Act of 1906-then
known as the Wiley Act-which prohibited interstate transport and sale of
misbranded or adulterated foods (Ziporyn 1985). This Act and the Federal
Meat Inspection Act, also passed that year, extended Federal responsibil-
ity into the arena of food safety. Significant revisions to the legislation
occurred in 1938 when the Food, Drug, and Cosmetic Act established
standards of identity and quality for certain foods, required ingredient
listings on food labels, and prohibited sales of foods that were determined
to be harmful to health. In 1958, the Food Additives Amendment to the
1938 Act shifted the burden of proof of safety to the manufacturer, required
that additives known to cause cancer in either humans or animals be
deemed unsafe (the Delaney Clause), and established the list of ingredients
in common use that were "Generally Recognized As Safe" (GRAS) for
human consumption. A 1960 Color Additives Amendment applied the
Delaney Clause to all chemical food coloring agents. Since 1969, a major
review has been under way of the safety of substances on the GRAS list
(Smith and Rulis 1981). Regulation of food safety is a shared responsibility
33
u Nutrition and Health
of several Federal agencies, primarily the USDA for plant, animal,
poultry production; the Food and Drug Administration (FDA) for all c
foods and additives; and the Environmental Protection Agency
pesticide contaminants.
The food labeling provisions of the 1906 and 1938 Acts were designe
protect consumers against fraudulent misbranding of foods, and this pc
was extended by the Fair Packaging and Labeling Act of 1%6, which cz
for accurate ingredient labeling on foods in interstate commerce (PC
1987). More recently, interest has grown in the use of food labels to edu
consumers about the nutritional quality of food and the role of nutritic
health. Regulations published in 1973 authorized voluntary nutrition la
ing and required nutrition labeling for fortified foods and those for WI
nutritional claims were made (Hutt 1981). In 1987, the FDA proposed a
policy for public health messages on food labels to permit health claim
package labels when the information is true and certain criteria are
(FDA 1987). Responsibility for regulating labeling and marketing prc
dures related to foods is shared by the USDA (meat, poultry, eggs), F
(all other foods) and, for advertising, the Federal Trade Commission (.
ter 1987).
Food Fortrjication. The onset of World War I brought new nutritic
concerns and focused attention on the need for an overall improvemer,
the availability of nutrients to the general population. The first food
tification program, instituted in 1924, was the addition of iodine to sal
prevent goiter. During the Second World War, this program was extendel
include enrichment of wheat flour with iron and the vitamins thian
niacin, and riboflavin. Also during the 1940's, milk was fortified v
vitamin D and margarine with vitamin A.
Food Assisrunce. As early as 1918, the idea of targeting food assistance
vulnerable population groups was proposed in the Children's Bureau p
lication Milk-The Indispensable Food for Children. Milk supplies 1
decreased and prices increased due to the effects of World War I, and
Children's Bureau advocated that children be given priority in allocat
milk supplies. Charitable organizations established milk stations and cc
munity kitchens to provide food supplements to the poor and to help peo
with limited income choose and prepare an adequate diet (Egan 1980
Widespread unemployment anda overty during the 1930's stimulated I
development of new Federal programs to provide food assistance to i
poor. At first, these programs focused exclusively on distribution of surp
agricultural commodities. In 1930, for example, the USDA and the Fede
34
Introduction and Background 0
Emergency Relief Administration began a distribution program as food
relief. The donation of surplus foods to child nutrition and school lunch
programs was authorized by amendments to the Agricultural Act in 1933.
The more formally organized Food Distribution Program was established
in 1935. An experimental Food Stamp Program was initiated by the Surplus
Commodities Corporation in 1939. The National School Lunch Program
was established in 1946, and the Special Milk Program was added in 1954
(U.S. Senate 1976).
In the early 1960's, as a result of surveys and assessments indicating special
needs among low-income populations (Citizens' Board 1968), the Federal
Government expanded its involvement in income support and direct deliv-
ery of food services. A pilot study in 1961 led to the Food Stamp Act of
1965, which authorized a small-scale program to meet limited needs for
food assistance. The Child Nutrition Act of 1966 established the School
Breakfast Program. Following the 1969 White House Conference on Food,
Nutrition, and Health (White House Conference 1970), eligibility and
benefits were enlarged for the Food Stamp, School Lunch, School Break-
fast, Special Milk, and Summer Food Programs; the Special Supplemental
Food Program for Women, Infants, and Children (WIG) was created;
general assistance reimbursements were increased (for the School Break-
fast and School Lunch Programs); and the Nutrition Program for the
Elderly was established through an amendment to the Older Americans
Act. From I%9 to 1977, Federal expenditures for these programs increased
from about $1.2 to $8.3 billion (U.S. Senate 1977a). By 1986, as many as 50
million Americans (the exact number is uncertain due to overlapping
benefits) were served by food assistance programs administered by the
USDA. The cost of these programs exceeded $18.8 billion in 1986 and $20
billion in 1987 (Matsumoto 1987).
Nutrition Services and Training. In the 1920's under the Federal Maternity
and Infancy Act, nutrition services were launched in nine State depart-
ments of public health. Enactment of the Social Security Act in 1935,
authorizing grants-in-aid to the States for health services for mothers and
children, was a major impetus for the further development of nutrition
services in State health agencies. By 1945, all but three States had one or
more nutrition consultant positions included in their budgets. Nutrition
services began to extend beyond maternal and child health during the late
1950's and early 1960's in response to new mental retardation, chronic
disease control, home health service, and nursing home and other ex-
tended care programs. Initiatives in primary health care, family planning,
and comprehensive health planning during the 1970's further expanded the
availability of nutrition services (Nutrition Services Project Committee
35
cl Nutrition and Health
1983), as did establishment of the Community Food and Nutrition Program
(CFN) in the 1980's to provide nutrition services to low-income popula-
tions (Office of Community Services 1987).
To ensure an adequate supply of health professionals to serve the popula-
tion, the Federal Government also supports health professions education
in primary care as well as public health practice. Since the 1940's, funds
have been available from Title V of the Social Security Act for nutrition
training of health professionals, and since 1957, various authorities under
Title VII of the Public Health Service Act have supported health profes-
sions students and curriculum development in applied nutrition, including
capitation grants to schools of public health that support traineeships for
public health nutrition students.
Food Intake and Nutrition Status Monitoring. The involvement of the
Federal Government in monitoring of food intake dates back to 1893 when
the USDA received an appropriation for this purpose (Porter 1986). The
USDA first began to collect data on the wholesale availability or "disap-
pearance" of food commodities in 1909. The subsequent annual collection
of such data has provided an important source of information on trends in
the availability of food, an indirect indicator of food use by the population
(Bunch 1987). Attempts to estimate actual food intake by the population
began in the 1930's. For example, household food purchases were exam-
ined by the USDA in 1936-37 through the first Nationwide Food Consump-
tion Survey (NFCS); such surveys have been conducted about every 10
years since, most recently in 1987-88 (USDA 1986,1987a, 1987b). Estima-
tions of the per capita nutrient content of the food supply began in the
1940's and are now reported annually (Marston and Raper 1986). The first
collections of data on the food consumption habits of individuals in
sampled households were performed by the USDA in 1%5 (NRC 1984).
Examples of food intake and availability data are given later in this chapter
in the section on dietary patterns.
Assessment of nutritional status emerged as a concern as early as 1918
when infants and children were weighed and measured during the opening
event of the Children's Year Campaign (initiated to "protect children from
the effects of war"). The impetus for this activity was the high percentage
of Selective Service rejections in World War I caused by conditions that
might have been prevented or corrected by adequate nutrition in early
childhood. The first studies of nutrition and child health were conducted by
the Children's Bureau in a mountainous section of Kentucky in 1920 and in
the industrial area of Gary, Indiana, in 1922 (Egan 1980).
36
Introduction and Background O
Much of the recent expertise in measuring human nutritional status was
developed through the work of the Interdepartmental Committee on Nutri-
tion for National Defense, which conducted nutrition surveys in more than
30 countries during the 1950's and 1960's. Attempts to evaluate the nutri-
tional status of the U.S. population began in 1956 when Congress autho-
rized the Department of Health, Education, and Welfare (DHEW) to
conduct periodic national health examination surveys; with the addition in
1971 of additional status measures, including a dietary intake component,
these surveys evolved into the National Health and Nutrition Examination
Surveys (NHANES). The first NHANES was conducted from 1971-74,
the second from 1976-80, and the Hispanic HANES from 1982-84 (DHHS/
USDA 1986). The third NHANES started in 1988. In l%8-70, in response
to increasing concern about the nutritional status of low-income popula-
tions, DHEW sponsored the Preschool (Owen et al. 1974) and Ten-State
(DHEW 1972) Nutrition Surveys and identified evidence of malnutrition in
these populations.
The dietary intake, health, and nutritional status surveys and surveillance
systems listed in Table l-4 and described above are components of the
National Nutrition Monitoring System-a complex assortment of inter-
connected activities that provide regular information about dietary intake
and nutritional status to the health of the American people and about
factors that affect diet and nutritional status (DHHS/USDA 1987). The
present system was proposed in 1978 in response to a congressional re-
quest in the 1977 Food and Agriculture Act that the Secretaries of Agri-
culture and of Health, Education, and Welfare, now Health and Human
Services (DHHS), develop a joint proposal for a comprehensive system
that would monitor the nutritional status of the American people. In 1981, a
Joint implementation Pfun (revised in 1987) committed the two Depart-
ments to close coordination of survey methods and to submission of
reports to Congress every 3 years on information gained from monitoring
activities. The National Nutrition Monitoring System includes efforts by
several Federal agencies to provide information about health and nutri-
tional status, food consumption, food composition, dietary knowledge and
attitudes, and food safety and quality.
Food and Nutrition Research. The Federal role in nutrition research began
in 1887 with the development of the forerunner of the National Institutes of
Health (NIH) as a one-room laboratory on Staten Island. In 1893, the
USDA was authorized to perform agricultural and human research. The
PHS Hygienic Laboratory developed into the first National Institute of
Health in 1930; subsequently, it was joined by other laboratories to create
37
Table 14
National Nutrition Surveillance Activities
0
2
1.
Category Activity
Departmenta Agencya Population Timing g.
J
Health and Nutritional
Status Measurements
National Health and
Nutrition Examination
Surveys
NHANES 1
NHANES I1
Hispanic HANES
NHANES III
DHHS CDC/NCHS
National Health DHHS
Interview Survey
NHIS Special Topics DHHS
NHANES I Epidemiologic DHHS
Followup
National Survey of Family DHHS
Growth
National Maternal and DHHS
Infant Health Survey
National Mortality Survey DHHS
CDC/NCHS
CDCR'XHS
CDC/NCHS
CDC/NCHS
CDC/NCHS Planned 1988
CDCMCHS
Vital Statistics DHHS CDC/NCHS
U.S. population,
special groups
l-74 yrs 1971-74
6 mo-74 yrs 1976-80
6 mo-74 yrs 1982-84
2 mo+ 1988-94
U.S. Annual
U.S. Selected topics
NHANES I older 1982-84, 1986,
persons 1987
Women 15-44 yrs 1976, 1983, 1987
Annual l%l-68,
1986
U.S. States,
counties, local
areas
Annual
Health and Nutritional
Status Measurements
(continued)
Coordinated State
Surveillance System
Behavioral Risk Factor
Surveillance System
Nutrition Research in
Support of Nutrition
Monitoringb
Food Consumption
Measurements
Nationwide Food
Consumption Survey
(NFCS)
Continuing Survey of
Food Intakes by
Individuals (CSFII)
1985 and 1986
1989 and beyond
NHANES
DHHS
CDCKHPE Pregnant women, Continuous
children
CDCKHPE Adults
Continuous
DHHS
USDA
NIH Varies Ongoing
ARS
CDCKHPE
FDA
USDA HNIS
U.S., low-income Every 10 years,
sample current 1987-88
USDA HNIS
DHHS
CDCINCHS
Women 19-50, Annual
their children,
men, low-income
sample zi
U.S. population, Annual (planned) E
low-income a
sample, other !?
U.S. population 1971-74, 1976-80,
1982-84, 1988-94 g
s
ii
Table 14 (continued)
Food Consumption Total Diet Study
Measurements (continued)
Vitamin/Mineral
Supplement Adverse
Reactions
Food Composition
Measurements
Nutrient Data Bank
Nutrient Composition
Laboratory
Food Labeling and
Package Survey
Total Diet Study
Fiber, Carotenoid, and
Vitamin A Comp. Studies;
Taurine and Biotin Comp.
Studies
Dietary Knowledge Health and Diet Survey
and Attitude Assessment
Survey of Infant Feeding
Practices
Survey of Weight-Loss
Practices
Cholesterol Awareness
Survey
DHHS
FDA
DHHS FDA
USDA
USDA
DHHS
DHHS
DHHS
DHHS
DHHS
DHHS
DHHS
HNIS
ARS
FDA
FDA
NIH/NCI
NIHI
NIDDK
FDA
FDA
FDA
NIHI
NHLBI
NIHI
NHLBI
+ FDA
Specific age-sex Annual
groups
U.S. Continuous
Continuous
Continuous
Annual and
biennial parts
Annual
Ongoing
Ongoing
U.S. adults .18-22 mo intervals
Pregnant women 1988 or 1989
U.S. adults 1987 or 1988
Physicians 1986
Adults
e
Dietary Knowledge and
Attitude Assessment
(continued)
Nursing and Dietitian
Survey
NHIS Special Topics
Health Promotion/
Disease Prevention
.
VitMn Supplement
Cancer Control
Food Supp!y
-
CSFII Followup
(Consumer Perceptions
Survey)
Physician Knowledge
Survey on Hypertension
Cancer Prevention
Awareness Program
Demand Studies
DHHS NIH/
NHLBI
DHHS CDC/NCHS U.S. adults
+ NIH/NCI
USDA/DHHS HNIS
FSIS
FDA
DHHS NIH/NHLBI
DHHS NIH/NCI
USDA ERS
Nurses, dietitians 1986, 1987
1985
1986
1987
U 3. population Planned 1989-%
Physicians 1978-88
U.S. adults 1984 + ongoing
U.S. population Continuous
Determinations
aARS = Agricuftural Research Service, CDC = Centers for Disease Control, CHPE = Center for Health Promotion and Education, DHHS =
Department of Health and Human Services, ERS = Economic Research Service, FDA = Food and Drug Administration, FSIS = Food Safety
and Inspection Service, HNIS = Human Nutrition information Service, NCHS = National Center for Health Statistics, NCI = National Cancer
Institute, NHIS = National Health Interview Survey, NHLBI = National Heart, Lung, and Blood Institute, NIDDK = National Institute of Diabetes
and Digestive and Kidney Diseases, NIH = National Institutes of Health, USDA = U.S. Department of Agriculture.
blncludes research on nutritional status assessment and requirements throughout the life cycle. The nutritional status research focuses on (1)
indices of nutritional status, (2) micromethods to measure nutrient concentrations in various tissues and plasma, and (3) methods that improve
accuracy of dietary intake data.
Source: U.S. Department of Health and Human Services and U.S. Department of Agriculture 1987.
n
u Nutrition and Health
the present research enterprise of NIH (Simopoulos 1986). In 1975, the
NIH Nutrition Coordinating Committee was established to address NIH
nutrition issues that span the goals and purposes of 12 Institutes, 2 Divi-
sions, and 2 Centers within the agency. The FDA began conducting nutri-
tion research in 1938. By 1976, Federal expenditures for nutrition research
and research training exceeded $73 million (U.S. Senate 1976). The amount
was reported as nearly $200 million by 1979 (JSHNR 1980) and $270 million
in 1984, of which nearly $200 million represented research supported by
NIH (ICHNR 1986; NIH 1987). In 1987, NIH expended a total of $261
million, reinforcing its longstanding position as the major Federal agency in
biomedical and behavioral nutrition research and training support. This
nutrition research encompasses a broad range of topics, including health
maintenance, human development throughout the life cycle, disease pre-
vention, and disease treatment.
The Interagency Committee on Human Nutrition Research (ICHNR) was
established by the Secretaries of DHHS and USDA to succeed the Joint
Subcommittee on Human Nutrition Research that operated out of the
White House Office of Science and Technology Policy to coordinate all
Federal nutrition research activities. The ICHNR produced a 5-year plan
for human nutrition research that reviewed the research activities of eight
Federal agencies, listed research priorities, and identified six areas for
expanded research investigation: nutritional requirements at various
stages of the life cycle, nutrition interactions and bioavailability, nutrition
and chronic diseases, energy regulation and eating disorders, nutrition
monitoring, and nutrition education methodology (ICHNR 1986).
Dietary Guidance and Nutrition Education. The Federal Government has
supported efforts to teach the public about nutrition since 1867 when the
Office of Education was established with responsibility for nutrition educa-
tion within the public schools. The Children's Bureau of the Department of
Labor published Prenatal Care in 1913 and Znfant Care in 1914 to provide
dietary guidance to mothers. These books have been in publication ever
since and are all-time best sellers of the U.S. Government Printing Offtce.
The USDA also had an early role and published its first food selection
guide, designed to help parents meet the nutritional needs of young chil-
dren, in 1916 (Hunt 1916). Since that time, federally supported dietary
guidance materials have been issued and revised regularly to meet the
needs of specific target audiences and to reflect emerging knowledge of
nutritional science. A list of Federal dietary guidance publications for the
general public since 1917 is presented in Table l-5.
42
e
Table l-5
Federal Dietary Recommendations for the General Public, 1917-1988
Recommendationa
Year Agencyb
Publication
Maintain Include
Ideal Starch Limit
Body and Limit Limit Choles- Limit Limit
Variety Weight Fiber Sugar Fat terol Salt Alcohol
1917 USDA
1942 USDA
1943 USDA
1946 USDA
1946 USDA
1958 USDA
1977 U.S. Senate
1979 USDA
1979 DHEW
1979 DHEWINCI
What the Body Needs-
Five Food Groups
Food for Freedom-
Daily Eight
National Wartime Nutrition
Guide-Basic Seven
National Food Guide-
Basic Seven
Food for Growth-
Four Food Groups
Food for Fitness-
Four Food Groups
Dietary Goats for the U.S.
Building a Better Diet-
Five Food Groups
Healthy People: The Surgeon General's
Report on Health Promotion and
Disease Prevention
Statement on Diet, Nutrition,
and Cancer--Prudent
Interim Principles
+
+
+
+ * *
+ *
+ *
+ *
+
+
+ + + + + +
+ + + + + + +
+ + + + + + t
-I- t + +
Year Agencyb
Publication
0
z
5
Table l-5 (continued) g
Ei
Recommendationa 5
Maintain Include
Ideal Starch Limit i
Body and Limit Limit Choles- Limit 2
Variety Weight Fiber Sugar Fat terol salt Limit 5
Alcohol
1980 USDA/DHHS Dietary Guidelines for Americans + + + + + + + +
1980 DHHS National 1990 Nutrition Objectives + + + + + + + +
I984 DHHS/NHLBI Recommendations for Control + + + +
% 1985 USDA/DHHS of High Blood Pressure
Dietary Guidelines for Americans, + + + + + + + +
2nd edition
I986 DHHS/NCI Cancer Control Nutrition Objectives + + + +
for the Nation: 1985-2000
1987 DHHS/NHLBI National Cholesterol Education + + + + + +
Program Guidelines
1988 DHHS/NCI Dietary Guidelines for Cancer + + + + + +
Prevention
`!7ecommended for inclusion in the daily diet, as opposed to subsequent recommendations to limit intake.
aOther recommendations include: increased consumption of foods containing vitamins and minerals (USDA 1917-l 958; NCI 1988) increased
physical activity (USDA/DHHS 18881985; DHHS 1980). and reduced intake of salt-cured or smoked foods (NC1 1988).
bUSDA = U.S. Department of Agriculture, U.S. Senate = U.S. Senate Select Committee on Nutrition and Human Needs, DHEW = Department
of Health, Education, and Welfare, DHHS = Department of Health and Human Services, NCI = National Cancer Instiiute. NHLBI = National
Heart, Lung, and Blood Institute.
Introduction and Background O
The earliest federally sponsored guidelines advised the public to consume
portions from a variety of food groups every day to obtain sufficient energy
and to avoid nutritional deficiencies. As more was learned about nutrients
essential in the diet, recommendations began to emphasize consumption of
foods containing vitamins, minerals, and other "protective" dietary com-
ponents (Hertzler and Anderson 1974). In response to the economic crisis
of the 1930's, the USDA began to develop meal plans for consumers at
different levels of income to address issues of cost (Haughton, Gussow,
and Dodds 1987).
The first Recommended Dietary Allowances (RDA's) for intake of energy
and eight nutrients were developed by the National Research Council and
adopted at the wartime National Nutrition Conference in 1941 (Roberts
1958). RDA's have been published periodically since; the most recent
(ninth) edition appeared in 1980 (NRC 1980). Its recommendations are
reviewed later in this chapter. Also in 1941, the USDA, in cooperation with
the Offtce of Education and the PHS, published the first Federal guide to
incorporate information on specific vitamins and minerals and the first to
use the term "enriched." Meal plans and dietary guidelines published since
the 1940's have been designed increasingly to translate the RDA's into
terms usable by consumers (Hertzler and Anderson 1974). The USDA's
1958 Food for Fitness-A Daily Food Guide, written in terms of four food
groups, was the first to promote intake of specific nutrients-alcium,
vitamin A, and vitamin C-that were commonly consumed in amounts
substantially below RDA levels (Haughton, Gussow. and Dodds 1987).
Typically, an adequate diet has been defined as providing the basic food
groups that would contain amounts of essential nutrients-protein, vi-
tamins, and minerals-sufficient to prevent deficiency diseases. In the
mid-1970's, however, the focus of national policy objectives expanded to
encompass the role of overconsumption of fat, cholesterol, salt, sugar, and
alcohol as dietary factors associated with chronic disease. The increasing
scientific interest in these relationships led the U.S. Senate to hold hear-
ings on diet and health from 1973 through 1977 (U.S. Senate 1977a).
Expanding knowledge of the role of diet in health maintenance also led to
the development in 1975 of a DHEW Policy Statement on Health Aspects
of Nutrition (U.S. Senate 1976). Thus, dietary adequacy began to include
consideration of the most reasonable proportions of dietary factors for
prevention of chronic-rather than deficiency--diseases.
This new perspective was reflected in the two editions of the 1977 report
Dietary Goals for the United States, produced by the Senate Select Com-
mittee on Nutrition and Human Needs (U.S. Senate 1977b. 1977~). These
u Nutrition and Health
reports recommended significant changes in average dietary intake pat-
terns to improve protection against the principal chronic diseases. To
accomplish this goal, they established quantitative targets for consumption
of complex carbohydrates and naturally occurring sugars (greater than 48
percent of energy), refined and processed sugars (10 percent of energy),
total fats (less than 30 percent of energy), saturated fat (less than 10 percent
of energy), cholesterol (less than 300 mglday), and salt (less than 5 g/day)
(U.S. Senate 1977~).
These principles, although not the quantitative targets, were supported and
expanded in the 1979 report Healthy People: The Surgeon General's
Report on Health Promotion and Disease Prevention (DHEW 1979) and by
the 1980 publication Nutrition and Your Health: Dietary Guidelines for
Americans, jointly issued and revised in 1985 by the Departments of
Agriculture and of Health and Human Services (USDAIDHHS 1985). The
Guidelines recommend:
o Eat a variety of foods.
o Maintain desirable weight.
o Avoid too much fat, saturated fat, and cholesterol.
o Eat foods with adequate starch and fiber.
o Avoid too much sugar.
o Avoid too much sodium.
o If you drink alcoholic beverages, do so in moderation.
This approach reflects the increase in interest in the relation between
nutrition and prevention of chronic diseases, a development that has
shaped and mandated Federal nutrition education activities of the past
decade (see Table l-4) and is the principal focus of the discussion, conclu-
sions, and recommendations of this Report.
Scientific Background
Human Nutritional Requirements
Essential nutrients must be obtained from the diet in the proper amounts
and proportions to maintain good health and to prevent deficiency dis-
eases. A deficiency of an essential nutrient causes signs and symptoms that
can be prevented or cured by an increased intake of the nutrient. Such
deficiencies may be due to inadequate dietary intake, or they may be
46
Introduction and Background 0
induced by either inherited or acquired inabilities to absorb, transport,
store, or metabolize nutrients or by excessive losses of nutrients from the
body (for example, from vomiting, bleeding, or diarrhea).
Just as a deficiency of a nutrient can cause disease, too much of a nutrient
can also lead to disease. For example, as discussed throughout this Report,
the excessive consumption of energy, fat (especially saturated fat), and
alcohol have been associated with the development of specific chronic
disease conditions in some individuals. Excessive intake of some vitamins
and most of the minerals also has been shown to result in either acute or
long-term disorders. For most nutrients, there appears to be a safe and
adequate range of dietary intake that satisfies nutritional requirements but
does not cause untoward symptoms. This concept is illustrated in Figure
l-1. Ideally, the diet should contain energy and all of the essential nutrients
in amounts that fall within these ranges of intake.
I ( )I Y'o
.:.:.:.:.:.:.:.:.:.:.:.~..:.~.~:.:.~:.~.~: .:
.........................................
. .
........ . . ......................... , . .
. . ..:.1:.:.~:.:.:.:.:.:.:.:.: .:.
. . . . . . ...... . . . . . . ... . ...... . . . . . . ... . ............................
.....................................
......................................
..........................................................................
C :.:2..~:.:.~:.~:.:.:.:.:.:.:.~..~:.:.:.~:.:.:.:.:.:.:.:.:.:.: .
......................................
.z ..............................................................................
. ..... . . . . . . . . . . . ...... . ... . . . . . . . .... . . . . . . . . . . . . ...... . . . . . . . . . . ......
......................................
. . .....................................
5 ....................................
.....................................
.................................... . .
C :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.~:.:.:.:.:.~:.:.~.~.:.~~ ...
.....................................
3 .:::::::~::::::::~~::::::::::::::::::::::::::~::::~.::::~:::
L . ........................................
. . . .... . . . . . . ... . . ..... .................................................
.....................................
. .....................................
....................................
.................................... . .
.....................................
.....................................
..................................... .
.......................................
. . . . . . . . .... . . . . . . .
......................................................
.....................................
.................................................
. . . . . . . . . . .
.......................................................
... . .
... ......
...... . ... . . . . ............................................................
. . . . . . -. . .
. . . .
. . . .... ... ..... . . .
........ .
. . . . . . . ..................................................
. . . . ...... . . . . . . .... ...... . . . ... .... . . ........ .
......... ............................................................
..................................... .
....................................
.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.: . .
.............................
...............
~:.:.~:.:.~..:.:.:.:.:.:.:.:.:.:.:.~:.:.~:.:.:.~:.:.~..:.:.:.: .:
* Concrnkltion or intake of nutrient -
Figure l-l. Dependence of biologic function or tissue concentration on in-
take ol a nutrient. For nutrients and energy sources, there is a
range of intake that confers optiil physiologic function. Below
thII range, deficiincies can cause dii or death. Excecrsive
intake also can lead to increasiing symptoms of toxkity. The op-
timal range varies for each nutrient and is affected by many
indiiidual and environmental factors.
Source: Merlz, W. 1981. The essential trace elements. Science 213:1332-38. Copy-
right 1981 by the American Association for the Advancement of Science, re-
printed with permission.
47
u Nutrition and Health
Recommended Dietary Allowances
The need to establish goals for good nutrition in the United States was
recognized in the 1930's and led to the establishment in 1940 of the
Committee on Food and Nutrition, now called the Food and Nutrition
Board, of the National Research Council, National Academy of Sciences.
The Committee's initial purpose was to make sure that the population was
adequately nourished during World War II, and one of its early functions
was to recommend quantities of nutrients that should be provided to the
Armed Forces and the general population. These recommendations led to
the development of goals for intake of nine specific nutrients that would
meet the known nutritional requirements of men, women, and children of
varying ages. These first RDA's were adopted in 1941 (Roberts 1958), and
they have been published at 5- to lo-year intervals since 1943. Although the
original purpose of the RDA's was to promote nutritional health during
wartime, their purpose has expanded over the years to include use for
development of standards for food assistance programs, food labels, and
evaluation of dietary adequacies.
Because research on human nutritional requirements is often incomplete
or inconsistent, and because of variability in individual nutrient require-
ments, the RDA's represent an estimated, rather than an absolute, stan-
dard of dietary adequacy, and they are revised periodically to reflect
current scientific evaluation of the available nutrition research. The most
recent revision was published in 1980 and is presented in Table l-6 (NRC
1980). The RDA's are defined as ". . . the levels of intake of essential
nutrients considered, in the judgment of the Committee on Dietary Allow-
ances of the Food and Nutrition Board on the basis of available scientific
knowledge, to be adequate to meet the known nutritional needs of prac-
tically all healthy persons." Thus, each RDA is deliberately set higher than
the.actual requirement for that nutrient in most individuals.
Specific RDA's have been established for protein, 10 vitamins, and 6
minerals; they are presented in categories that vary according to body size.
gender, and energy consumption (NRC 1980). RDA's are usually higher for
males than for females, except for women who are pregnant or lactating.
For 12 additional nutrients, research has been too limited to establish
specific RDA's and the Food and Nutrition Board has proposed ranges of
daily intake that are considered "safe and adequate." These are presented
in Table l-7. The RDA's are designed to exceed the nutrient requirements
of most individuals, but the allowances for energy are designed to reflect
average needs for people of different heights and weights, ages, and activi-
ty levels.
48
Table l-6
Food and Nutrition Board, National Academy of Sciences-
National Research Council Recommended Daily Dietary Allowances,a Revised 1960
Designed for the maintenance of good nutrition of practically all healthy people in the U.S.A.
Fat-Soluble Vitamins
Age Weight Height Protein Vitamin A Vitamin D Vitamin E
(years) (kg) (lb) (cm) (in) w ha REJb (CLkT)C (mg a-TE)d
Infants 0.0-0.5 60 24 kgx2.2 420 IO 3
0.5-I .o x s 71 28 kgx2.0 400 IO 4
Children 1-3 13 29 90 35 23 400 IO 5
20 44 112 44 30 500 IO 6
7% 28 62 132 52 34 700 IO 7
Males 11-14 45 99 157 62 45 loo0 IO 8
% 15-18 66 145 176 69 56 looo IO IO
B-22 154 177 70 loo0 7.5 10
23-50 z 154 178 i: loo0 5 IO
51+ 70 154 178 :: 56 loo0 5 IO $
Females 11-14 46 101 157 62 46 800 IO 8 1
15-18 55 120 163 64 46 800 IO
19-22 55 120 163 64 44 800 7.5 t 0
g.
23-50 55 120 163 44 800 5 8 1
51+ 55 120 163 iii 44 800 5 8 B
Pregnant +30 +200 +5 +2 e
Lactating +20 +400 +5 +3 m
R
aThe allowances are intended to provide for individual variations among most normal persons as they live in the United States under usual en- 9
vironmental stresses. Diets should be based on a variety of common foods to provide other nutrients for which human requirements have been
less well defined. s
Wetinol equivalents; 1 RE = 1 kg retinol or 6 pg $ carotene.
CAs cholecalciferol; 10 pg cholecalciferol = 4000 IU of vitamin D.
da-tocopherol equivalents: 1 mg d-a tocopherol = 1 a-TE.
Table l-6 (continued) 0
2
Water-Soluble Vitamins
Age Weir& s:
Height Vitamin C Thiamin Riboflavin Niacin Vitamin B, Folacinr Vitamin B,,
(years) (kg) (lb) (cm) (in) b-fg) (mg) (mg) (mg NEP (mg) h3) (Ia) iz
E
infants 0.0-0.5 6 13 0.
60 24 35 0.3 0.4 6 0.3 30 0.5g X
0.5-1.0 9 20 71 28 35 0.5 0.6 8 0.6 45 1.5 i!
Children l-3 29 90 35 45 0.7 0.8 9 0.9 loo 2.0 g
:i 44 II2 44 45 0.9 1.0 II 1.3 200 2.5
7% 28 62 132 52 45 1.2 1.4 I6 1.6 300 3.0
Males II-14 45 99 I57 62 50 I.4 1.6 18 400 3.0
15-18 66 I45 176 69 60 I.4 1.7 I8 :*: 400 3.0
19-22 70 154 177 70 60 1.5 1.7 19 212 400 3.0
3 23-50 70 154 178 70 60 I.4 1.6 18 2.2
51+ 70 154 I78 70 60 1.2 I.4 16 2.2 z :-I
Females II-14 46 IO1 157 62 50 I.1 1.3 I5 1.8 400 3:o
15-18 55 120 163 64 60 I.1 1.3 14 2.0 400 3.0
19-22 55 120 163 64 I.1 1.3 14 2.0 3.0
23-50 55 I20 163 64 2 1.0 1.2 I3 iti 3.0
51+ 55 120 163 64 60 1.0 1.2 I3 El 400 3.0
Pregnant +20 +0.4 + 0.3 +2 + 0.6 +400 +1.0
Lactating +40 +0.5 +0.5 +5 +0.5 +100 +1.0
eNiacin equivalent; 1 NE = 1 mg of niacin or 60 mg of dietary tryptophan.
f The folacin allowances refer to dietary sources as determined by Lactobacillus casei assay after treatment with enzymes (conjugates) to make
polyglutamyl forms of the vitamin available to the test organism.
@Ihe recommended dietary allowance for vitamin B12 in infants is based on average concentration of the vitamin in human milk. The allowances
after weaning are based on energy intake (as recommended by the American Academy of Pediatrics) and consideration of other factors, such
as intestinal absorption.
Table l-6 (continued)
Age
(years)
Minerals
Weight Height Calcium Phosphorus Magnesium Iron Zinc Iodine
(kg) (lb) (cm) (in) bud (mid @x3) kg) bf3) (I%)
Infants 0.045 6 13 60 24 360 240 50 10 : 40
0.5-1.0 9 20 28 540 360 70 15 50
Children l-3 13 29 iz 35 800 800 150 15 10 70
7% 20 28 44 62 112 132 44 52 800 800 800 800 200 250 IO 10 IO IO 120 90
Males 11-14 45 1: 157 62 1200 1200 350 18 I5 150
15-18 66 176 69 1200 1200 400 18 15 150
Y 19-22 70 154 177 70 800 800 350 10 15 150
23-50 70 154 178 70 800 800 350 IO 15 150
51+ 70 154 178 70 800 800 350 10 15 I50
Females II-14 46 101 157 62 1200 1200 300 I8 I5 150
15-18 55 120 163 64 1200 1200 300 I8 I5 150 z
19-22 55 120 163 64 800 800 300 18 I5 I50 8
23-50 55 120 163 64 800 800 300 I8 I5 I50 E
51+ 55 120 163 64 800 800 300 IO I5 I50 g
Pregnant +400 +400 + I50 h +5 + 25 3
Lactating +400 +400 + I50 h + 10 +50 B
a
hThe increased requirement during pregnancy cannot be met by the iron content of habitual American diets nor by the existing iron stores of m
many women; therefore, the use of 3040 mg of supplemental iron is recommended. Iron needs during lactation are not substantially different Pi
from those of nonpregnant women, but continued supplementation of the mother for 2-3 months after parturition is advisable to replenish
stores depleted by pregnancy. f
Source: National Research Council 1980. bi
0
O Nutrition and Health
Table 1-7
Estimated Safe and Adequate Daily Intakes
of Selected Vitamins and Mineralsa
Age
(years)
Vitamins
Vitamin K
(PIit)
Biotin
(Ia)
Panto-
thenic
Acid
(mg)
Infants O-O.5 12 35 2
0.5-l lo-20 50 3
Children and l-3 15-30 65 3
Adolescents 30 20-40 85 3-4
30-60 120 4-5
11+ 50-100 100-200 47
Adults 70-140 100-200 &7
Trace Element+
Man- Molyb-
Age Copper ganese Fluoride Chromium Selenium denum
Wars) (mg) (mg) (mg) (mg) (mg) Ow)
Infants O-O.5 0.5-0.7 0.5-0.7 0.14.5 0.014.04 0.01-0.04 0.03-0.06
0.5-l 0.7-1.0 0.7-1.0 0.2-1.0 0.02-0.06 0.02-0.06 0.0.08
Children and l-3 1.0-1.5 1.0-1.5 0.5-1.5 0.02-0.08 0.02-0.08 0.05-0.1
Adolescents 4-6 1.5-2.0 1.5-2.0 l&2.5 0.03-0.12 0.03-0.12 0.06-0.15
7-10 2.0-2.5 2.0-3.0 1.5-2.5 0.05-0.2 0.05-0.2 0.10-0.3
II+ 2.0-3.0 2.5-5.0 1.5-2.5 0.05-0.2 0.05-0.2 0.15-0.5
Adults 2.0-3.0 2.5-5.0 1.54.0 0.05-0.2 0.05-0.2 0.15-0.5 -
Electrolytes
Age Sodium Potassium Chloride
(years) (mg) (mg) (mg)
Infants O-O.5 I 15-350 350-925 275-700
0.5-l 25fL750 425-1275 400-1200
Children and l-3 325-975 550-1650 500-1500
Adolescents EO 450-1350 775-2325 700-2100
600-1800 100&3000 925-2775
11+ 900-2700 1525-4575 14Ot+t200
Adults 1100-3300 1875-5625 1700-5100
aBecause there is less information on which to base allowances, these figures are not
given in the main table of RDA and are provided here in the form of ranges of recom-
mended intakes.
Wecause the toxic levels for many trace elements may be only several times usual in-
takes, the upper levels for the trace elements given in this table should not be habitually
exceedad.
Source: National Research Council 1980.
52
Introduction and Background 0
The fact that most RDA's are intentionally established to exceed the
nutrient requirements of most people means that a dietary intake below the
RDA is not necessarily inadequate for an individual whose requirement for
a nutrient is average or even above average (NRC 1980). It also means that
the small percent of persons who- have unusually high nutrient require-
ments may not meet nutritional needs even when they consume nutrients at
RDA levels. The RDA's are estimates of the nutrient requirements for
populations rather than for individuals. In addition, RDA's may need to be
modified for people who are ill or injured.
Translating the RDA's into a single, universally applicable, ideal pattern of
food choices that best supports health and longevity is, for many reasons,
difficult. As noted above, individual nutrient requirements depend upon
complex interactions between genetic and environmental factors and the
stage of physiologic development. The nutritional needs of infants. young
adults, and older persons vary, and dietary habits and preferences differ
markedly from culture to culture and from individual to individual.
A definition of the food choices that best fu!fill nutrient requirements has
been a goal of the many Federal agencies and private health organizations
that have developed sets of dietary recommendations during the past
decade (Dwyer 1983; McNutt 1980). Some of these recommendations are
noted in Table 1-5; the evidence on which they are based is presented
throughout this Report. Most current recommendations emphasize that it
is the overall dietary pattern that determines whether or not nutrient
intakes are likely to fall within desirable ranges. Public health concerns
about specific nutrients, therefore, usually are directed to the kinds and
amounts of foods consumed and to the genetic, behavioral, and environ-
mental factors that affect food choices.
The diet must contain adequate energy, all essential nutrients, and certain
other dietary factors to sustain normal growth, development, and health.
The nutrients and dietary factors discussed in this Report include carbohy-
drates, fats, and proteins-the macronutrients-which are sources of ener-
gy as well as of essential fatty acids and amino acids that either cannot be
synthesized or are synthesized in amounts inadequate to meet body needs;
micronutrients-vitamins and mineral elements-which are necessary in
small amounts; and substances such as fiber, which does not fall into either
category but is nonetheless beneficial for good health. This section defines
these nutrients as background for this Report. Basic information on essen-
tial nutrients has been reviewed extensively (see, for example, Nutrition
Reviews 1984; Passmore and Eastwood 1986; Schneider, Anderson, and
Coursin 1983; Shils and Young 1988).
53
LJ Nutrition and Health
Energy
The diet must supply sufficient energy to support growth and development,
maintain basic physiologic functions, meet the demands of muscle activity,
and repair damage caused by illness or injury. In the United States, energy
intake and expenditure are measured in kilocalories, abbreviated as kcal,
and referred to as Calories or, commonly, calories. In international usage,
the term is kilojoules, abbreviated kJ (1 kcal=4.184 kJ). In this Report, the
terms energy and calories are used interchangeably to refer to the general
concept of energy; specific measures of energy intake or expenditure or the
energy value of food are given in kilocalories.
The body obtains chemical energy from food from the oxidation (chemical
burning) of protein, fat, carbohydrate, and, when it is consumed, alcohol.
The oxidation within the body of 1 g each of these substances in pure form
yields about 4,9, 4, and 7 kcal, respectively. Thus, fat contains more than
twice the caloric value of either protein or carbohydrate. The health signiti-
cance of the relatively high energy value of alcohol is discussed in the
chapter devoted to this topic.
Body weight depends on complex physiologic controls of the balance
between energy intake and energy expenditure. Both intake and expendi-
ture are equally important in regulation of body weight. Weight increases
when more energy is consumed than expended. Over time, such an imbal-
ance can lead to obesity. The physiologic controls of that balance and the
ways in which diet and exercise affect body weight are reviewed in the
chapter on obesity.
Carbohydrates
Carbohydrates are sources of energy for vital metabolic processes and also
are constituents of cellular substances such as nucleic acids, glycoproteins,
and enzyme cofactors and structural components of cell walls and cell
membranes. Carbohydrates are classified as monosaccharides, disac-
charides, and polysaccharides. Monosaccharide and disaccharide sugars
are referred to as simple carbohydrates and the polysaccharides (starches
and fibers) as complex carbohydrates.
Monosaccharides. Monosaccharides are simple sugars that do not need to
be further digested to be absorbed. The most important dietary monosac-
charides are glucose, fructose, and galactose. Glucose and fructose are
found in fruits, vegetables, and honey. They are also products of the
digestion of sucrose (table sugar) and, in the case of glucose, other disac-
charides. The glucose obtained from corn starch can be converted by
54
Introduction and Background O
enzymatic processes to fructose to produce high fructose corn sweeteners.
As discussed below, galactose is a subunit of the disaccharide lactose.
Disaccharides. Sugars formed from two monosaccharides are called disac-
charides. Sucrose, common table sugar, is composed of glucose and fruc-
tose. It is found in many fruits and vegetables but occurs in especially high
concentrations in sugar beets and sugar cane. Maltose is a disaccharide of
two glucose molecules and is found in beer, glucose syrups, and cereals.
Lactose, the sugar of milk, is composed of one molecule of glucose and one
of galactose.
Polysaccharides. Starch, glycogen, and most types of fiber are large. high-
molecular weight polysaccharides. Starch and glycogen are composed of
glucose molecules. Fiber includes a variety of carbohydrates and other
components. These molecules differ from each other in the ways their
monosaccharide units are linked to each other and, therefore, in their
ability to be digested to sugars that can be absorbed into the body. The
chemical linkages in starch and glycogen can be split by human intestinal
enzymes, but those of polysaccharides found in fiber are, by definition,
indigestible although some fiber components can be broken down by
enzymes released by bacteria in the digestive tract to short-chain fatty
acids that can be reabsorbed and furnish small amounts of energy.
Fiber. Dietary fiber is a term used to describe a heterogeneous group of
plant food components that are resistant to human digestive enzymes
(LSRO 1987). Not all are fibrous in the usual sense of the word, and some
are even soluble. Dietary fiber includes some of the structural components
of plant cell walls (e.g., cellulose and noncellulosic polysaccharides such as
hemicellulose) and certain nonstructural components of cells such as pec-
tins, gums, brans, mucilages, algal polysaccharides, and modified cel-
lulose.
Specific types of dietary fiber are often classified as soluble or insoluble on
the basis of their response to extraction methods. In general, the soluble
fibers include gums, mucilages, and some pectins and hemicelluloses,
while insoluble fibers include cellulose, lignin, and other pectins and
hemicelluloses. Although all fruits, vegetables, and grains contain these
fiber components, some are especially good sources of one or another type.
Oat bran and beans, for example, contain relatively large proportions of
soluble fibers whereas wheat bran is a good source of insoluble fiber. In
general, diets that contain large amounts of fiber add bulk and may confer
greater feelings of satiety.
55
The effect\ of the WI'WU~ fiber types on intestinal function differ, however.
Insoluble fibers that adsorb water increase stool weights. Some soluble
fibers have been found in short-term studies to reduce blood cholesterol,
enhance glucose tolerance, and increase insulin sensitivity (LSRO 1987).
These issues are reviewed in appropriate chapters of this Report.
Lipids
Dietary fats or lipids include a variety of substances soluble in organic
solvents, such as chloroform or benzene, but insoluble in water. Food lipids
include triglycerides (composed of fatty acids and glycerol), phospholipids,
and cholesterol. Any excess of energy in the body, whether derived from
carbohydrate, fat, protein, or alcohol, can be converted to fatty acids and
stored in adipose tissue triglyceride, but dietary fat is essential because it
supplies linoleic acid (an essential fatty acid) and it is a vehicle for absorp-
tion of fat-soluble substances such as the vitamins A, D, E, and K (NRC
1980).
Lipids are concentrated sources of energy as well as structural components
of cell membranes and are molecular precursors for the synthesis of hor-
mones and other substances. In adults, these functions usually can be met
by a daily intake of 15 to 25 g of fat (NRC 1980), a level well below that
typical of current American diets. In addition, fats impart characteristic
mouth-feel and flavors to foods and increase the feeling of satiety after
meals by delaying the passage of food from the stomach to the small
intestine. The reservoirs of fat stored in the body protect the body's organs,
provide insulation from heat loss, and maintain energy production during
long periods of reduced food consumption, such as in starvation, dieting, or
serious illness or injury.
Furt.v Acids. Fatty acids are molecules containing carbon. hydrogen, and
oxygen with chain lengths ranging from 4 to about 25 carbon atoms. A small
amount of food fat occurs as phospholipid. Most fat in food, however,
occurs as triglycerides, three fatty acid chains attached to a glycerol
molecule. Triglycerides are called fats or oils depending on whether they
are solid or liquid at room temperature. Both provide concentrated sources
of metabolizable energy, about 9 kcal/g, more than twice the level of either
proteins or carbohydrates. Recent studies suggest that the caloric value of
fat may appear even higher in growing rats, reflecting greater efficiency of
utilization under certain circumstances (Donato and Hegsted 1985; Donato
1987).
56
Introduction and Background 0
The fatty acids commonly found in food are usually composed of an even
number of carbon atoms, usually 12 to 22, and contain from 0 to 6 double
bonds-sites where additional hydrogen atoms can be attached. The
number of double bonds determines the degree of saturation of fats. Fatty
acids with no double bonds are saturated, those with one double bond are
monounsaturated, and those with two or more double bonds are polyun-
saturated.
Although all dietary fats consist of a mixture of saturated, monounsatu-
rated, and polyunsaturated fatty acids, fatty acids in foods of animal origin
are more often saturated, while those in plants are more likely to be
monounsaturated and polyunsaturated. There are some important excep-
tions to this generalization. Coconut oil and palm kernel oil contain a high
proportion of saturated fatty acids even though they are derived from
plants, and as discussed below, certain fish are good sources of polyunsatu-
rated fatty acids.
The location of double bonds along the carbon chain is also of physiologic
importance. The site of the double bonds is used to categorize unsaturated
fatty acids into three groups-the omega-3, omega-6, and omega-9 fatty
acids. In the metabolism of fatty acids, the end of the carbon chain
containing the methyl group (whose carbon atom is known as the omega
carbon) tends to remain unchanged, whereas enzymes can add or subtract
carbon atoms or double bonds starting from the end of the molecule that
contains the carboxyl group. For convenience, the chemical features of
fatty acids are usually described in terms of the structure at the methyl end
of the chain. Oleic acid has nine carbon atoms between its methyl omega
carbon atom and its closest double bond, so it belongs to the omega-9
family of fatty acids. Linoleic acid and the compounds to which it is
connected in the body have six carbons between their omega carbons and
closest double bonds, and they are omega-6 fatty acids. Linolenic acid and
its derivatives have three carbons between the omega carbon and the
closest double bond and are omega-3 fatty acids.
Monounsaturated omega-9 fatty acids such as oleic and palmitoleic acids
are not essential in the human diet because they can be synthesized
biochemically within the body. Linoleic acid, an omega-6 fatty acid, can-
not be synthesized by the human body and must be consumed in the diet. It
is a component of cell membranes and is required for the synthesis of
arachidonic acid, the major precursor of prostaglandins, prostacyclins,
thromboxanes, and leukotrienes that influence many physiologic pro-
51
0 Nutrition and Health
cesses, including blood vessel dilation, platelet aggregation, smooth mus-
cle contraction, inflammation, and reproduction. Linoleic acid is widely
distributed in the fatty portion of both plant and animal foods. Vegetable
seed oils are especially rich sources. Symptoms of its deficiency have been
reported among infants restricted to skim milk and among children and
adults fed intravenous solutions lacking fat (Rivers and Frankel 1981).
Linoleic acid deficiency can be prevented by consuming about 3 to 5 g of
linoleic acid a day, an amount considerably less than that consumed by the
average adult in the United States. Thus, essential fatty acid deficiencies
are reported rarely in the United States (NRC 1980).
The role of omega-3 fatty acids, particularly eicosapentaenoic acid and
docosahexaenoic acid, in human nutrition and health is under active inves-
tigation. Omega-3 fatty acids are present in the human brain, retinal lipids,
and phosphoglycerides of synaptic membranes. Of current interest are the
potential health effects of these highly polyunsaturated fatty acids derived
from linolenic acid (omega-3).
Recent epidemiologic, clinical, and experimental data suggest that
omega-3 fatty acids may have important physiologic effects that cannot be
met by omega-6 or omega-9 fatty acids. Some of these effects are reviewed
in the chapter on coronary heart disease.
Cholesterol. Cholesterol is a fatty substance required for synthesis of sex
hormones, bile acids, and vitamin D, and it is an important constituent of
all cell membranes. It is both synthesized in the body (endogenous) and
obtained from the diet (exogenous) and is not, therefore, an essential
nutrient. In normal individuals, endogenous synthesis of cholesterol is
reduced when blood cholesterol levels are high. When the physiologic
mechanisms that regulate this feedback mechanism are insufficient, blood
cholesterol levels can rise and increase the risk for coronary heart disease
(see that chapter). Dietary cholesterol is found only in foods derived from
animals (meat, poultry, fish, eggs, and dairy products); it is not present in
plants.
Protein
Body proteins serve many functions; they include structural components
of cells and tissues, enzyme catalysts of biochemical reactions, peptides
and hormone messengers, and components of the immune system. The
amino acids in proteins can also serve as sources of energy, and most can
be used to synthesize glucose when dietary carbohydrate is inadequate.
Some amino acids are needed for the synthesis of special compounds;
58
Introduction and Background 0
tryptophan, for example, is required for synthesis of serotonin (a neu-
rotransmitter) and niacin (a vitamin).
Proteins are formed from various combinations of amino acids that are
linked together in chains ranging from several to hundreds in length. Each
plant and animal species has its own characteristic proteins that are distin-
guished by the sequence of amino acids. Plants can synthesize all of their
amino acids from the elements carbon, oxygen. hydrogen, nitrogen, and
sulfur, but humans lack the ability to synthesize at least eight amino acids
and must obtain them from the diet. The rest are called nonessential amino
acids because, although needed for protein synthesis, they are not required
in the diet. Essential amino acids include isoleucine, leucine, lysine, methi-
onine, phenylalanine, threonine, tryptophan, and valine. The amino acid
cystine can replace part of the requirement for methionine, and tyrosine
can replace part of the requirement for phenylalanine. Histidine is an
essential amino acid for infants, but its essentiality for adults has not been
conclusively demonstrated (NRC 1980).
The proteins in different foods vary in their biologic value due to their
content and balance of amino acids. When the concentration of one essen-
tial ammo acid is low relative to the others, that amino acid is considered
limiting and the protein is said to be incomplete. The presence of limiting
amino acids in incomplete proteins can be compensated for at least par-
tially by dietary intake of complementary proteins, those with different
limiting amino acids. When consumed together or within a short time (the
exact length of time has not been defined), such proteins can meet require-
ments for essential amino acids. This explains, in part, why strict vege-
tarians can maintain good health without eating foods derived from ani-
mals. The addition of even a small amount of protein from animal foods can
improve amino acid intake. The RDA's for protein intake of men, women,
and children of different ages are given in Table l-6.
Vitamins
Vitamins are organic (carbon-containing) compounds that are essential in
very small amounts for health, growth, and reproduction. They must be
obtained from the diet either because they cannot be synthesized at all by
the body or because the amounts made are insufficient to meet require-
ments. Vitamins are classified according to their solubility in fat or water,
and this property affects their occurrence in foods as well as their absorp-
tion, transport, storage, and metabolism.
59
t.~,r-.~,,/rr/~/e C'itclmins. The fat-soluble vitamins are vitamins A, D, E, and
k. These vitamins are generally found in high concentrations in the fatty
portions of food and are absorbed, transported, metabolized, and stored
along with fat. Their absorption requires bile and dietary fat. They are
transported in the body by the same mechanisms by which fat is trans-
ported, are bound to lipoproteins or specific transport proteins, and are
stored in liver and fat tissue. Fat-soluble vitamins are excreted into the
intestine in bile and are either reabsorbed or are eliminated in feces. They
are not excreted to any appreciable extent in urine. Because excretion of
fat-soluble vitamins is minimal, excess intake is more likely to cause
toxicity symptoms. For the same reason, deficiencies are reported rarely
among healthy adults, although they are observed among children who are
growing rapidly and who lack adequate fat stores and among children or
adults who have disease conditions that interfere with fat metabolism, such
as malabsorption, biliary obstruction, or renal or liver disease. The RDA's
for vitamins A, D, and E are given in Table 1-6; the estimated safe and
adequate intake of vitamin K is shown in Table l-7.
Vitamin A is present in the diet both as the vitamin and its precursor.
Retinol, or preformed vitamin A, is found in foods derived from animals
(milk, butter, egg yolks, liver) and, when bound to a fatty acid, is used to
fortify many foods. Retinol occurs in foods primarily in the ester form.
Certain carotenoids (pigments found in many dark green, yellow, and
orange vegetables, fruits, and egg yolks) can be converted by the body into
retinol. The conversion of beta-carotene into retinol occurs mainly in the
intestinal mucosa. Retinol circulates in the plasma bound to a specific
transport protein called retinol-binding protein. Excess amounts are stored
in the liver. Bxcessive intake of retinol has caused toxic symptoms (head-
ache, skin and bone disorders, and renal failure) among people consuming
abnormally large amounts of vitamin supplements, or-less commonly-
liver from animals with high vitamin A levels (Selhorst et al. 1984; Ma-
honey et al. 1980). High intakes of retinol supplements have also been
associated with birth defects (Rosa 1986); synthetic retinoid analogs, used
to treat a variety of skin disorders (Bollag 1983), can cause fetal malforma-
tions. They are hazardous to pregnant women or women planning to
become pregnant (Lammer et al. 1985) and should be used only under
medical supervision. Excess amounts of beta-carotene are stored in body
fat deposits. Excessive intake of foods rich in beta-carotene, such as
carrots, is not known to cause toxic effects. It raises levels of carotene in
the blood and can cause the skin to take on an orange color that disappears
when the carotene consumption declines. Vitamin A is essential for visual
processes, for the normal differentiation of epithelial tissue, for the regula-
tion of cell membrane structure and function, and for the maintenance of
60
Introduction and Background O
immunocompetence. Vitamin A deficiency, through adverse effects on eye
epithelial tissues, is a major cause of blindness among children in many
developing countries, and it is also responsible for substantial additional
illness. Recent studies of children consuming inadequate levels of retinol
or carotenes suggest that retinol supplementation may improve their sur-
vival (Sommer et al. 1986; Tarwotjo et al. 1987).
Vitamin D, (cholecalciferol or calciol) is synthesized from a precursor (7-
dehydrocholesterol) in skin that becomes activated by exposure to ultra-
violet light from the sun. It is essential in the diet only when exposure to sun
is inadequate. The vitamin is converted by the liver to 25-dihydrox-
yvitamin D (calcidiol) and then further converted by the kidney to 1,25-
dihydroxyvitamin D (calcitriol), the metabolically active form. Excess
vitamin D can be toxic, especially to children and adults who have kidney
disease or certain metabolic disorders. The metabolism and functions of
vitamin D are reviewed in detail in the skeletal diseases chapter.
Vitamin E functions as an antioxidant. Its principal dietary sources are
vegetable seed oils. Its deficiency has been associated with a hemolytic
anemia in premature infants and with neurologic symptoms in adults.
Vitamin K functions as an activator of blood clotting proteins, proteins in
bone and kidney, and the formation of other proteins that contain gamma-
carboxyglutamic acid (GLA). It is synthesized by intestinal bacteria. Thus,
deficiencies generally occur only in infants whose intestinal flora has not
yet been established, in children and adults receiving antibiotic or anti-
coagulant therapy (see chapter on drug-nutrient interactions), and in indi-
viduals with disease conditions that interfere with intestinal absorption.
Vitamins E and K are less toxic than vitamins A or D.
Water-Soluble Vitamins. The water-soluble vitamins include vitamin C
(ascorbic acid) and those of the B-complex group: biotin, folate, niacin,
pantothenic acid, riboflavin, thiamin, vitamin B,, and vitamin B,,. The
RDA's for vitamin C, thiamin, riboflavin, niacin, vitamin B,, folacin, and
vitamin B,, are presented in Table 1-6; the safe and adequate ranges of
intake of biotin and pantothenic acid are given in Table l-7. These vitamins
are generally found in whole grain cereals, legumes, leafy vegetables, and
meat and dairy foods. The two exceptions are vitamin C, which can be
obtained in adequate amounts only from fruits and vegetables, and vitamin
B,,, which is made by bacteria and found only in foods of animal origin.
Water-soluble vitamins are absorbed from the intestine, and most are
stored in a form that is bound to enzymes or transport proteins and
excreted in urine. Thus, they should be supplied in adequate amounts in the
daily diet even though tissue depletion may take as long as weeks or
months.
61
0 Nutrition and Health
Water-soluble vitamins are essential components of enzymes and enzyme
systems that catalyze a wide variety of biochemical reactions in cellular
energy production and biosynthesis. Thus, deficiencies of these vitamins
particularly affect tissues that grow or metabolize rapidly, such as skin,
blood, and the cells of the digestive tract and nervous system. Common
deficiency symptoms are skin disorders, anemia, malabsorption and diar-
rhea, neurologic disorders, and defects in tissues of the mouth. Specific
vitamin deficiencies infrequently occur in the United States. When defi-
ciencies occur, they usually are found along with other deficiencies and are
due to diseases or to consumption of highly restricted diets or excessive
amounts of alcohol or drugs that interfere with vitamin metabolism. The
risk for deficiencies is greater in growing infants (see maternal and child
nutrition chapter) and, perhaps, in older persons (see chapter on aging).
Substantial intake of these vitamins causes toxicity infrequently, although
severe toxic reactions have been reported from very excessive intakes of
niacin and vitamin B,.
Minerals
Minerals perform a number of roles in the body. They function as inorganic
components of enzyme systems that catalyze the metabolism of protein,
carbohydrate, and lipids. Some act to regulate fluid and electrolyte bal-
ance, to provide rigidity to the skeleton, and to regulate the function of
muscles and nerves. Minerals also work together with vitamins, hormones,
peptides, and other substances to regulate the body's metabolism.
Essential minerals are often classified as macrominerals, required in
amounts from several hundred milligrams to 1 or more grams a day (cal-
cium, phosphorus, magnesium, sodium, potassium, and chloride), or as
trace elements-iron, zinc, iodine, copper, manganese, fluoride, chro-
mium, selenium, molybdenum, and cobalt (as a component of vitamin
B&-which are required in small amounts (Underwood 1977). Other
minerals such as nickel, vanadium, silicon, or boron have been shown to be
essential under rigorous conditions for experimental animals but do not
have well-established functions in humans. Still others, such as lead or
mercury, are potentially toxic. RDA's for six minerals are given in Table
1-6. Ranges of dietary intake considered safe and adequate are given for
nine others in Table l-7.
Minerals are distributed in a variety of foods, but they usually are present
in limited amounts. Thus, diets must contain enough of a variety of foods to
meet daily requirements. People consuming diets low in energy for pro-
62
Introduction and Background 0
longed intervals are at risk of developing mineral deficiencies. Deficiencies
can also result from therapy with medications that interfere with mineral
absorption and metabolism; alcoholism, renal disease, or gastrointestinal
diseases (see relevant chapters); and causes of mineral loss such as bleed-
ing or diarrhea. Toxic symptoms can result from consumption of excessive
amounts of almost any mineral or as a result of defective regulation of
absorption or inadequate excretion.
Dietary Patterns
There are two types of data for monitoring dietary patterns: food availabili-
ty and dietary intake. Food availability data are derived from annual
estimates of per capita availability of selected commodities in the food
supply. These data are useful in examining changes over time in the
availability of agricultural commodities. Estimates of dietary intake come
from periodic national food consumption surveys of individuals.
Time Trends in the Availability of Foods
Food availability data are produced by the USDA and are derived from
annual production and marketing estimates of food products that are then
usually adjusted for imports, exports, and stock changes. Such data have
been collected since 1909 and have been published as a historical series
from 1909 to the mid-MO's (USDA 1968). Data for the most recent 20
years are published annually (Bunch 1987). Per capita estimates of food
availability are derived by dividing the total amount of food available by the
total U.S. population. These data represent economic rather than phys-
iologic consumption because they estimate the amount of food available at
wholesale and retail levels rather than actual intake by individuals. Certain
limitations restrict use of such data as proxies for consumption--for exam-
ple, the difficulty in correcting for wastes and losses that occur before
consumption by individuals, for inedible food components and food for
human consumption fed to pets, or for variabilities in intakes of population
subgroups.
Nonetheless, food availability data provide useful information when used
within their appropriate limits of interpretation. Time trend changes in
availability of foods are best estimated from these data because the data
have been available on an annual basis for many years. At the current time,
these data are also the best source of information for tracking changes in
the use of commodities or products that can be substituted for one another
(e.g., partial substitution of high-fructose corn syrup for refined sugar).
63
O Nutrition and Health
A summary of the recent trends is noted below, taken mainly from the data
of the last two decades as presented in Table 1-8 (Bunch 1987), but in part
from the early data series as well (USDA 1968).
Overall, total per capita availability of meat, poultry, andfish increased by
about 10 percent since 1965-67, primarily due to increases in poultry and
fish and shellfish. Availability of red meat increased substantially after
World War II (USDA 1968) but, after peaking in about 1970, has since
declined to approximately 1965-67 levels.
Egg availability reached its peak about 1950. During the past 20 years, it
has declined by about 18 percent; this is approximately equivalent to a
decrease of one egg per week per person (from about six to five eggs per
week).
The availability of fluid whole milk declined by 48 prp"nt from 1965-67,
while available levels of low-fat milk and milk products (including yogurt)
more than doubled from 1%547 to 1983-85. Cheese availability also more
than doubled during this period.
Availability off&s and oils increased by approximately 23 percent since
1965-67, primarily due to a 77 percent increase in salad and cooking oil and
a 36 percent increase in shortening. Butter availability was about 18 lb per
capita per year in 1909 (USDA 1968) and has declined to about 5 lb,
including about a 20 percent decline since 1965-67 (Bunch 1987). Availabil-
ity of total animal fat also declined by 1983-85, to levels approximately 80
percent of those in 1%5-67, but with a slight recent increase. Over the two
decades, vegetable sources increased from 67 percent to 79 percent of all
fats and oils-in marked contrast to the first half of the century when
animal sources provided most of the fats and oils (USDA 1968).
As noted earlier, these data represent availability of commodities and thus
do not necessarily reflect changes in actual intakes of fats and oils by the
U.S. population. For example, there is no correction for losses of fats and
oils used for deep fat frying, which are discarded after use rather than
consumed. Second, the bulk data represent only fats and oils that are added
to foods or used in table spreads; they do not include "hidden" fats in foods
such as marbled fat in meats or the fats in nuts.
Vegetable undfruit availability increased from 1%567 by 19 percent and 7
percent, respectively, primarily due to increases in availability of fresh
produce. There was, however, no consistent change in availability of
legumes (beans, peas, and nuts) or starchy vegetables (potatoes and sweet
notatoes).
64
Table 1-8
Annual Per Capita Availability of Selected Commodities in the
U.S. Food Supply, 198!%1989
(pouts)
Meat, Poultry, and Fishb Dairy Productsd
Low-fat Milke
Fluid and Milk
Fish and Whole Products
Year Meat Poultry Shellfish Total Ew Milk (fluid) Cheese' Totab
1965-67 123.6 30.6 10.8 165.0 40.0 240.3 41.7 9.8 343.9
z 1968-70 130.8 33.0 11.3 175.1 39.5 219.5 54.6 11.0 334.6
1971-73 129.5 35.1 12.3 176.9 38.2 199.2 69.3 12.9 327.7
1974-76 128.7 35.5 12.4 176.6 35.1 176.0 82.9 14.9 317.1
1977-79 126.2 40.1 13.0 179.3 34.6 155.9 95.3 16.8 310.2 g
1980-82 120.9 44.2 12.7 177.8 33.9 138.1 101.7 18.7 299.7
1983-85 120.9 47.6 13.8 182.3 32.8 125.3 111.4 21.5 301.7 &
C
aTotals may include more categories than the selected commodities. a.
bMeat (beef, veal, pork, lamb), poultry, and fish, edible weight. Fish excludes game fish (Bunch 1987, Table 9, p. 15). B
cEggs, retail weight. Weight of a dozen eggs is assumed to be 1.57 lb (Bunch 1987, Table 8, p. 14).
d Dairy products are for civilian population, except fluid milk and cream data, which use U.S. resident population (Bunch 1987, Table 10. p. 16). f2
BLOW-fat and other milk products include low-fat, skim, buttermilk, flavored drinks, and yogurt. 2
`Cheese is whole and part-whole milk cheese, excluding pot, baker's, and cottage cheese. 6
gTotal dairy products calculated as total retail product weight minus butter (Bunch 1987, Table 10, p. 16). Includes frozen dairy products, cot- g
tage cheese, and other products not indicated in table. The amount of calcium contributed by this food group has actually increased slightly
during the 20-year period shown, as a result of increases in products such as dry milk powder. g
0
Table l-8 (continued)
Year
1965-67
I 968-70
g: 1971-73
1974-76
1977-79
1980-82
1983-85
Fats and Oil@
Animal Vegetable
Salad and
Total Cooking Total
Butter Lard Animal Margarine Shortening Oil Vegetable Total
5.9 5.7 16.9 10.3 15.4 12.6 35.2 52. I
5.5 5.0 16.0 10.7 16.9 14.4 38.8 54.9
4.9 3.7 14.1 11.0 17.2 16.7 41.9 56.0
4.5 2.9 II.6 Il.4 17.2 18.5 44.8 56.4
4.4 2.3 II.6 Il.3 17.9 20.0 46.3 57.9
4.4 2.5 12.8 II.2 18.4 21.6 48.1 60.9
4.9 2.0 13.5 10.5 20.9 22.3 50.6 64.1
Fruit@ 2.
Fresh Processed Total
79.0 35.3 114.3
77.1 37.6 114.7
75.5 39.4 114.9
79.9
80.4 2: 120.5
120.2
84.8 37:1 121.9
87.9 34.8 122.7
hFood fats and oils calculated on a total population basis except butter, which is based on civilian population (Bunch 1987; animal and vegeta-
ble fats are from Table 2, p. 7; butter, lard, margarine, shortening, and salad and cooking oil are from Table 12, p. 18). The animal and vegeta-
ble categories are not strictly distinct because some margarines and shortenings include animal fats.
I Selected fruits, retail weights. Include fruits for which data are available for the entire series: oranges, tangerines, tangelos, lemons and limes,
grapefruit, apples, avocados, bananas, cherries, grapes, nectarines, peaches, pears, pineapples, plums and prunes, strawberries, minor fruits,
and a variety of canned, frozen, and chilled fruit and juices (Bunch 1987, Table 2, p. 7).
Table l-8 (continued)
Vegetablesi Sugar and Sweeteners'
Potatoesk
Beans, and Flour and Refined Total
Peas, and sweet Cereal Cane Corn Caloric Coffee, Tea
Year Fresh Processed Total Nuts Potatoes Pruducts and Beet Sweeteners Sweeteners and Cocoa
1%5-67 62.6 41.4 104.0 14.8 84.5 143.8 97.6 15.5 114.8 15.1
% 1968-70 65.2 45.4 110.6 14.8 85.1 141.9 100.6 18.2 120.4 14.5
1971-73 66.1 45.9 112.0 14.2 80.6 138.5 101.7 21.8 125.0 14.2
1974-76 68.9 46.1 115.0 15.1 81.5 143.6 92.7 27.3 121.4 13.1
1977-79 71.7 46. I 117.7 14.3 81.5 145.8 91.7 33.8 126.X II.1
1980-82 74.3 44.2 118.6 * 14.0 76.3 150.2 78.9 44.4 124.6 II.3 $
1983-85 79.7 44.7 123.3 14.6 79.5 150.5 67.4 58.3 127.1 II.6 0
I Selected vegetables: fresh vegetables for which data are available for entire series include broccoli, carrots, cauliflower, celery, corn, lettuce, g
onions and shallots, and tomatoes; 1985 data for processed vegetables are unavailable (Bunch 1987, Table 2, p. 7). g.
kPotatoes and sweet potatoes: data not comparable to pre-1980 figures. Data revised to reflect conversion from processed weight to fresh- 1
weight equivalent to dehydrated potatoes, frozen potatoes, chips, and shoestrings (Bunch 1987, Table 2, p. 8). E
a
1 Sugars and sweeteners, dry weight basis (Bunch 1987, Table 27, p. 33). r
m Nutrition and Health
Availability of jlour and cereal products showed both decreasing and
increasing fluctuations during the 20-year period; 1983-85 levels were
approximately 5 percent higher than 1%5-67 levels. Availability of grains
was at its lowest point this century in 1971-73, but has since increased by
about 9 percent.
Availability of sugars and sweeteners increased by about 11 percent since
1965-67. It should be noted that the availability data for sugars and sweet-
eners are for bulk commodity forms only; they do not include estimates of
sugars that are consumed as a natural constituent of food products, for
example, lactose in milk or sugars naturally present in fruits.
Availability of coffee, tea, and cocoa decreased approximately 25 percent
since 1%5-67.
Current Dietary Intakes
Food consumption surveys can be used to estimate food and nutrient
intakes of populations and population subgroups. The most recent nation-
ally representative survey is the first Continuing Survey of Food Intakes by
Individuals (CSFII), conducted by the USDA in 1985. Data are limited to
three subgroups: children 1 through 5 years and adult men and women 19
through 50 years of age. Results are presented based on 1 day of intake
(Table l-9). When applicable, estimated mean intakes are compared with
recommendations in the latest report on RDA's (NRC 1980). In interpret-
ing results, it should be noted that the RDA's (except for energy) have a
margin of safety above average requirements. Thus, diets that do not meet
the RDA's do not by themselves provide conclusive evidence of nutritional
deficiencies. Corroborating health data are needed.
Food Energy. Men and children had estimated mean intakes of more than
90 percent of the Recommended Energy Intakes (REI); for women, the
estimated mean intake was 82 percent of the REI.
Total Fat, Fatty Acids, and Cholesterol. Fat contributed 34 percent of total
energy intake for children and 36 to 37 percent for men and women. The
relative fatty acid contributions were approximately 40 percent saturated,
40 percent monounsaturated, and 20 percent polyunsaturated. Cholesterol
intakes ranged from a mean of 254 mglday for children to 304 and 435 mg for
women and men, respectively.
Protein. For men, women, and children, estimated mean intakes were 140
percent or more of the RDA. Protein contributed approximately 16 percent
of total energy intakes.
68
Introduction and Background cl
Table l-9
Mean Daily Intake of Food Energy, Nutrients, and Food
Components for Men, Women, and Young Children From the
Continuing Sutvey of Food Intakes by Individuals (CSFII), 198!jb
Men Women Children
Total Food Energy (% REW (94) (82) (loo)
Fat [% total energy]
Total fat
Saturated fatty acids
Monounsaturated fatty acids
polyunsaturated fatty acids
Cholesterol mg
Protein
[(9$ tgflrgyl
Carbohydrates I% total energy]
Dietary Fiber g
Vitamins (% RDA)
Vitamin A
Vitamin E
Vitamin C
Thiamin
Riboflavin
Niacin
Vitamin B,
Vitamin B,*
Folacin
Minerals (% RDA)
Calcium
Phosphorus
Iron
Zinc
Magnesium
Minerals (ESADDI)'
Sodium
Potassium
1361
t131
(141
171
435
1163
(175)
[451
18
(122)
(98)
(182)
(124
(129)
(146)
(85)
(245)
(76)
(115) (78)
(192) (126)
(159) (61)
(94) (60)
(94) (72)
(exceeds)
(within)
(within)
(within)
(371
[I31
If41
t71
304
[161
(144)
1461
12
(127)
(97)
(133)
(110)
(115)
(130)
(61)
(156)
(51)
[341
[I41
1121
161
254
[161
(222)
1521
10
(215)
(108)
(186)
(153)
(197)
(151)
(127)
(192)
(157)
(105)
(132)
(88)
(84)
(121)
(exceeds)
(l-3 years exceeds)
(4-5 years within)
(below)
(below)
Copper (below)
+&mated mean daily intake is expressed in several ways: amount of intake, percent of
total energy intake, percent of Recommended Dietary Allowance, or comparison wrth Es-
timated Safe and Adequate Daily Dietery Intake.
bData based on 1 -day dietary recalls obtained by personal interview for !58 men 19 to 50
years of age for 1 459 women 19 to 50 yeers of age, and for 489 of !herr chrldren.1 to 5
years of age'in 19& (unweighted numbers). Nutrient Intakes do not Include vrtamln and
mineral supplements or sodium from salt added at the table.
~Recommended Energy Intake (NRC 1980); Source of percentages: NFCS, CSFII Report
Nos. 85-l and 85-3 (USDA 1985,1986).
dRecommended Dietery Allowance (NRC 1980); Source of percentages: NFCS, CSFII Re-
port Nos. 65-1 and 85-3 (USDA 19851989).
*Estimated Safe and Adequate Daily Dietary Intake (NRC 1980).
69
O Nutrition and Health
Diel